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Abstract: This poster reports on an initiative to implement HIV rapid testing in substance abuse treatment programs in the state of South Carolina. A multi-agency collaboration between the Single State Authority, the state Health Department, the regional Addiction Technology Transfer Center (ATTC), and one substance abuse treatment program (Lexington-Richland Alcohol and Drug Abuse Council (LRADAC)), facilitated state-wide implementation. LRADAC, a community-based treatment program, was one of twelve sites that participated in the CTN trial on HIV rapid testing (protocol CTN-0032). Upon completion of the trial, LRADAC implemented a rapid HIV testing and counseling program as a clinical service. South Carolina’s previous efforts to implement on-site rapid HIV testing in 10 pilot agencies had less than optimal success due to the absence of a successful model on which agencies could base their implementation plan. With support from the collaborating agencies, staff developed and presented a 2 1/2 day HIV testing and counseling curriculum at the annual SC School of Alcohol and Drug Studies in 2010. Following the successful completion of the course, participants were fully certified to conduct testing and counseling in their local programs. Course participants had the opportunity to learn the counseling and testing procedures that LRADAC staff found successful in implementing their program. Although challenging, implementing HIV testing program in substance abuse treatment programs is feasible for agencies. The multi-agency collaboration in South Carolina supported the development of an HIV testing and counseling course that was team taught and showcased a successful model on which implementation could be based. Consequently, this effort increased the likelihood that additional substance abuse agencies within the state would move forward with implementation. Related protocols: CTN-0032

Abstract:

Current HIV testing guidelines recommend that all adolescents and adults aged 13–64 be routinely screened for HIV in healthcare settings. Sexually transmitted disease (STD) clinic patients represent a population at increased risk for HIV, justifying more frequent risk assessment and testing. This analysis describes missed opportunities for HIV testing among a sample of STD clinic patients to identify areas where HIV testing services may be improved. Secondary analysis was conducted using data from Project AWARE, a randomized trial of 5012 adult patients from 9 STD clinics in the United States, enrolled April–December 2010. HIV testing history, healthcare service utilization, and behavioral risks were obtained through audio computer-assisted self-interview. Missed opportunities for HIV testing, defined as having a healthcare visit but no HIV test in the last 12 months, were characterized by location and frequency. Of 2315 (46.2%) participants not tested for HIV in the last 12 months, 1715 (74.1%) had a missed opportunity for HIV testing. These missed opportunities occurred in both traditional (54.9% at family doctor, 20.3% at other medical doctor visits) and non-traditional (28.5% at dental, 19.0% at eye doctor, 13.9% at correctional facility, and 13.3% at psychology visits) testing settings. Of 53 participants positive for HIV at baseline, 16 (30.2%) had a missed testing opportunity. Missed opportunities for HIV testing were common in this population of STD clinic patients. There is a need to increase routinized HIV screening and expand testing services to a broader range of healthcare settings.

Related protocols: CTN-0032, Project AWARE

Abstract:

This is the Results Article for CTN-0056-Ot.

Multistage, stepwise HIV testing and treatment procedures can result in lost opportunities to provide timely antiretroviral therapy (ART). Incomplete engagement of patients along the care cascade translates into high preventable mortality. This study aimed to identify whether a structural intervention to streamline testing and linkage to HIV health care, the “One4All” intervention, would improve testing completeness, ART initiation, and viral suppression and reduce mortality.

This cluster-randomised, controlled trial in Guangxi, China was conducted in 12 hospitals, similar in structural characteristics, past patient caseloads, and testing procedures. Hospitals were randomly assigned (1:1) to either the One4All intervention or standard of care. Hospitals were randomised in a block design and stratified by the historical rate of testing completeness of the individual hospital during the first 6 months of 2013.

A total of 478 patients were enrolled (232 in One4All, 246 in standard of care). They were aged 18 years or older who were identified as HIV-reactive during screening in study hospitals, who sought inpatient or outpatient care in a study hospital, and who resided in the study catchment area. The One4All strategy incorporated rapid, point-of-care HIV screening and CD4 counts, and in-parallel viral load testing, to promote fast and complete diagnosis and staging and provide immediate ART to eligible patients. Participants in control hospitals received standard care services. All enrolled patients were assessed for the primary outcome, which was testing completeness within 30 days, defined as completion of three required tests and their post-test counselling. Safety assessments were hospital admissions for the first 90 days and deaths up to 12 months after enrolment.

Although no difference was observed between study groups in the number of hospital admissions at 90 days, by 12 months there were 65 deaths (28%) in the in the One4All group compared with 115 (47%) in the standard-of-care group (Cox proportional hazard ratio 0·44, 0·19–1·01, p=0·0531). The One4All package of interventions also substantially increased the odds of achieving testing completeness within 30 days and ART initiation within 90 days.

Conclusions: The study provides strong evidence for the benefits of a patient-centered approach to streamlined HIV testing and treatment that could help China change the trajectory of its HIV epidemic, and help to achieve the goal of an end to AIDS. Taken together with new, strong evidence of the benefits of treating all people with HIV regardless of CD4 level, a patient-centered approach to streamline HIV testing and ART initiation regardless of CD4 count is clearly beneficial.

Related protocols: CTN-0056-Ot

Abstract:

HIV testing is the foundation for consolidated HIV treatment and prevention. This study aimed to discover the most relevant variables for predicting HIV testing uptake among substance users in substance use disorder treatment programs by applying random forest (RF), a robust multivariate statistical learning method. It also provides a descriptive introduction to this method for those who are unfamiliar with it. This secondary analysis used data from the NIDA Clinical Trials Network HIV testing and counseling study (CTN-0032). A total of 1281 HIV-negative or status unknown participants from 12 U.S. community-based substance use disorder treatment programs were included and were randomized into three HIV testing and counseling groups. The a priori primary outcomes was self-reported receipt of HIV test results. Classification accuracy of RF was compared to logistic regression, a standard statistical approach for binary outcomes. Variable importance measures for the RF model were used to select the most relevant variables. RF based models produced much higher classification accuracy than those based on logistic regression. Treatment group is the most important predictor among all covariates, with a variable importance index of 12.9%. RF variable importance revealed that several types of condomless sex behaviors, condom use self-efficacy and attitudes towards condom use, and level of depression are the most important predictors of receipt of HIV testing results. There is a non-linear negative relationship between count of condomless sex acts and the receipt of HIV testing.

Conclusions: RF seems promising in discovering important factors related to HIV testing uptake among large numbers of predictors and should be encouraged in future HIV prevention and treatment research and intervention program evaluations.

Related protocols: CTN-0032

Abstract:

Sexually transmitted infections (STIs) are significant public health and financial burdens in the United States. This manuscript examines the relationship between substance use and prevalent and incident STIs in HIV-negative adult patients at STI clinics.

A secondary analysis of Project AWARE was performed based on 5012 patients from 9 STI clinics. STIs were assessed by laboratory assay and substance use by self-report. Patterns of substance use were assessed using latent class analysis. The relationship of latent class to STI rates was investigated using Poisson regression by population groups at high risk for STIs defined by participant’s and partner’s gender.

Drug use patterns differed by risk group and substance use was related to STI rates with the relationships varying by risk behavior group. Substance use treatment participation was associated with increased STI rates.

Conclusion: Substance use focused interventions may be useful in STI clinics to reduce morbidity associated with substance use. Conversely, gender-specific sexual health interventions may be useful in substance use treatment.

Related protocols: CTN-0032, Project AWARE

Abstract:

The NIDA Clinical Trials Network trial of rapid HIV testing/counseling in 1281 patients (protocol CTN-0032) was a unique opportunity to examine relationships among substance use, depressive symptoms, and sex risk behavior. In this ancillary examination of the study data, past 6-month substance use, substance use severity, depressive symptoms, and three types of sex risk behavior (unprotected sex occasions [USOs] with primary partners, with nonprimary partners, and while high/drunk) were assessed. Zero-inflated negative binomial analyses were provided: probability and rate of sex risk behavior (in risk behavior subsample). Levels of sexual risk behavior were high, while variable across the three types of sex risk behaviors. Among the patients, 50.4% has engaged in USOs with primary partners, 42% in sex while drunk or high, and 23.8% in USOs with nonprimary partners. Similar factors were significantly associated with all three types of sex risk behaviors. For all types, problem drinking, cocaine use, and substance use severity had an exacerbating effect. Older age was associated with lower risk behavior, other relationship categories (e.g., married, separated/divorced, cohabitating) were associated with greater risk behavior than was single status. Depressive symptoms were associated with decreased likelihood of USOs with a primary partner.

Conclusions: Sexual risk behavior is common among individuals in outpatient substance abuse treatment. Results highlight the roles of problem drinking (e.g., up to three-fold) and cocaine (e.g., up to twice) in increasing sex risk behavior. They also demonstrate the utility of distinguishing between partner types and presence/absence of alcohol/drugs during sex. Findings argue for the need to integrate sex risk reduction into drug treatment, in both the assessment and counseling process. Addressing sexual risk behavior may enhance relapse prevention in this vulnerable population.

Related protocols: CTN-0032

Abstract:

Substance users are at increased risk for HIV and HCV infection. Still, many substance use treatment programs (SUTP) fail to offer HIV/HCV testing. This secondary analysis of data from the National Drug Abuse Treatment Clinical Trials Network study CTN-0032, 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 been tested.

Conclusions: This analysis demonstrates the potential for community-based substance use treatment programs to identify substance users at-risk for HIV and HCV infection. Access to high quality care and service attentive to the unique needs of substance users is vital to realizing optimal results in both HIV and HCV, reducing the incidence of late diagnosis, extending life expectancy, improving health outcomes and overall quality of life, and decreasing the use of costly medical services. Bundled HIV/HCV testing and linkage to care issues are recommended for expanding testing in community-based SUTP settings.

Related protocols: CTN-0032

Abstract:

There are an estimated 3.2 million individuals in the United States who are chronically infected with hepatitis C virus (HCV), of whom only have had an HCV antibody test and less than a quarter have had a confirmatory HCV RNA test. The US Centers for Disease Control and Prevention (CDC) has set a goal to reduce the proportion of HCV-infected individuals unaware of their status from 55% to 33%. This analysis of data from the National Drug Abuse Treatment Clinical Trials Network, study CTN-0032 (HIV Rapid Testing and Counseling), aimed to evaluate the cost-effectiveness of rapid HCV and simultaneous HCV/HIV antibody testing in substance abuse treatment programs. Researcher 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). Measurements included lifetime costs (2011 US dollars) and quality-adjusted life years (QALYs) discounted at 3% annually and incremental cost-effective ratios (ICERs).

On-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 and HIV testing in substance abuse treatment programs is cost-effective at a <$100,000/quality-adjusted life years threshold. On-site rapid HCV and HIV testing in substance abuse treatment programs represents good value as a public health investment. Policymakers should identify ways to improve the capacity of substance abuse treatment programs to implement on-site HCV and HIV testing, bill for these services, and ensure that individuals testing positive for either virus receive further evaluation and treatment.

Related protocols: CTN-0032, CTN-0032-A-1

Abstract:

Rapid HIV testing in high-risk populations can increase the number of persons who learn their HIV status and avoid spending clinic resources to locate persons identified as HIV infected. For this analysis, the authors determined the cost to sexually transmitted disease (STD) clinics of point-of-care rapid HIV testing using data from 7 public clinics that participated in a randomized trial of rapid testing with and without brief patient-centered risk reduction counseling in 2010. Costs included counselor and trainer time, supplies, and clinic overhead. National labor rates and test costs were applied, and the authors also calculated median clinic start-up costs and mean cost per patient tested, as well as projecting incremental annual costs of implementing universal rapid HIV testing compared with current testing practices.

Criteria for offering rapid HIV testing and methods for delivering nonrapid test results varied among clinics before the trial. Rapid HIV testing cost an average of US$22/patient without brief risk reduction counseling and US$46/patient with counseling in these 7 clinics. Median start-up costs per clinic were US$1,100 and US$16,100 without and with counseling, respectively. Estimated incremental annual costs per clinic of implementing universal rapid HIV testing varied by whether or not brief counseling is conducted and by current clinic testing practices, ranging from a savings of US$19,500 to a cost of US$40,700 without counseling and a cost of US$98,000 to US$153,900 with counseling.

Conclusions: Universal rapid HIV testing in STD clinics with same-day results can be implemented at relatively low cost to STD clinics if brief risk reduction counseling is not offered. STD clinics may be able to reallocate savings from less case finding for newly identified HIV-positive individuals lost to follow-up to offset some of these incremental costs. The benefits to patients may be substantial, including more rapid identification and linkage to care of HIV-infected individuals, avoiding return visits to receive results, and less emotional stress waiting for results.

Related protocols: CTN-0032, Project AWARE

Abstract:

This is the Results Article for Project AWARE.

To increase human immunodeficiency virus (HIV) testing rates, many institutions and jurisdictions have revised policies to make the testing process rapid, simple, and routine. A major issue for testing scale-up efforts is the effectiveness of HIV risk-reduction counseling, which has historically been an integral part of the HIV testing process. The objective of Project AWARE, an adaptation of CTN-0032, was to assess the effect of brief patient-centered risk-reduction counseling at the time of a rapid HIV test on the subsequent acquisition of sexually transmitted infections (STIs). From April to December 2010, Project AWARE randomized 5012 patients from 9 sexually transmitted disease (STD) clinics in the United States to receive either brief patient-centered HIV risk-reduction counseling with a rapid HIV test or the rapid HIV test with information only. Participants were assessed for multiple STIs at both baseline and 6-month follow-up. Participants randomized to counseling received individual patient-centered risk-reduction counseling based on an evidence-based model. The core elements included a focus on the patient’s specific HIV/STI risk behavior and negotiation of realistic and achievable risk-reduction steps. All participants received a rapid HIV test.

The prespecified outcome was a composite end point of cumulative incidence of any of the measure STIs over 6 months. All participants were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum (syphilis), herpes simplex virus 2, and HIV. Women were also tested for Trichomonas vaginalis. Results found no significant difference in 6-month composite STI incidence by study group (adjusted risk ratio, 1.12; 95% CI, 0.94-1.33). There were 250 of 2039 incident cases (12.3%) in the counseling group and 226 of 2032 (11.1%) in the information-only group.

Conclusions: Risk-reduction counseling in conjunction with a rapid HIV test did not significantly affect STI acquisition among STD clinic patients, suggesting no added benefit from brief patient-centered risk-reduction counseling. These study findings lend support for reconsidering the role of counseling as an essential adjunct to HIV testing. This inference is further buttressed by the additional costs associated with counseling at the time of testing; without evidence of effectiveness, counseling cannot be considered an effective use of resources. Posttest counseling for patients testing HIV-positive remains essential, however, both for addressing psychological needs and for providing and ensuring follow-through with medical care and support.

Comment: Haukoos JS, Thrun MW. Eliminating prevention counseling to improve HIV screening. JAMA 2013;310(16):1679-1680.

Related protocols: CTN-0032, Project AWARE

Abstract:

Previous research on HIV/AIDS-related services in substance use disorder (SUD) treatment has generally focused on the availability of HIV testing with less consideration of other prevention and supportive services. This study examines the adoption of HIV/AIDS-related services in treatment programs affiliated with the National Drug Abuse Treatment Clinical Trials Network (CTN), with comparisons between opioid treatment programs (OTPs) and SUD treatment programs. Face-to-face interviews were conducted in 2011-2012 with administrators and clinical directors of 167 treatment programs that were members of the CTN. Dichotomous indicators measured whether programs: (1) conducted HIV risk assessments at treatment intake; (2) offered HIV education/prevention; (3) had adopted on-site HIV testing; (4) offered support groups for people with HIV/AIDS; and (5) provided on-site medical monitoring for people with HIV/AIDS (e.g., monitoring HAART compliance). HIV risk assessment (86.2%) and HIV prevention/education (79.1%) were widely adopted by treatment programs in the CTN. About 54.7% of programs offered on-site HIV testing, consisting of 30.8% of programs using rapid HIV tests and another 23.9% using non-rapid tests. Fewer programs provided HIV support groups (22.9%) and medical monitoring for people with HIV/AIDS (24.8%). Opioid treatment programs were more likely than other SUD programs to offer on-site HIV testing and support groups for people with HIV/AIDS.

Conclusions: Although most treatment programs assess risk behaviors and offer HIV prevention/education, only half of the treatment programs within the CTN provide on-site HIV testing, which is a critical strategy for ensuring that patients receive their test results. Testing services have become widespread, however, within opioid treatment programs, which may reflect heightened concerns regarding the transmission of HIV/AIDS through injection drug use for their patient population.

Abstract:

This research brief describes the outcomes from National Drug Abuse Treatment Clinical Trials Network protocol CTN-0032, “HIV Rapid Testing and Counseling,” which found that patients offered HIV testing at centers where they received treatment for substance abuse were four times as likely to be tested as patients referred offsite. The study also supported current CDC advice to omit pretest risk reduction counseling — study participants whose test offer was prefaced with 5 minutes of information about the procedure, and those who received 30 minutes of risk reduction counseling, accepted testing at roughly equal rates. Both groups also reported similar frequencies of sexual risk behaviors during the 6 months subsequent to their test offers. Twelve CTN-affiliated treatment centers throughout the US took part in the trial, with researchers concluding that brief procedural information with an offer of onsite testing was the intervention of choice. With less expenditure of staff time and resources, it yielded rates of test completion and sexual risk reduction that were equal to those obtained with counseling and an offer of onsite testing, and greater than those obtained with offsite referral.

Related protocols: CTN-0032

Abstract:

Social workers are often on the front lines of the HIV/AIDS epidemic delivering prevention education and interventions, offering or linking individuals to HIV testing, and working to improve treatment access, retention, and adherence, especially among vulnerable populations. Individuals with substance use disorders face additional challenges to reducing sexual and drug risk behaviors, as well as barriers to testing, treatment, and antiretroviral therapy adherence.

This article presents current data on HIV transmission and research evidence on prevention and interventions with substance abusers, and highlights how individual social workers can take advantage of this knowledge in practice and through adoption and implementation with organizations. Research from the National Drug Abuse Treatment Clinical Trials Network (CTN) about rapid HIV testing and gender-specific HIV risk reduction interventions is described.

Related protocols: CTN-0018, CTN-0019, CTN-0032

Abstract:

This is the Results Article for CTN-0032-A-1.

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.

This article reports on outcomes from ancillary investigation CTN-0032-A-1 (“Economic Analysis of HIV Rapid Testing in Drug Abuse Treatment Programs”) in which the cost-effectiveness of three HIV testing strategies used in 12 community-based substance abuse treatment programs was evaluated: off-site testing referral, on-site rapid testing with information only, and 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. Referral for off-site testing was found to be less efficient (dominated) compared to offering on-site testing with information only. The cost-effectiveness ratio for on-site testing with information is $60,400/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 offered with information only in substance abuse treatment programs increases life expectancy at a cost-effectiveness ratio < $100,000/QALY. Policy makers 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.

Related protocols: CTN-0032-A-1

Abstract:

This day-long conference, co-sponsored by the Western States Node, featured presentations focused on the theme of innovations in treatment.

Presentations included:

Health Information Technology’s Role in the Integration of Delivery Systems for Primary Care and Substance Abuse (Keynote Address) — Wilson Washington, Jr, MS, Center for Substance Abuse Treatment (CSAT/SAMHSA)

Integrating Alcohol and Drug Treatment with Primary Care: A Medical Home Model — Connie Weisner, DrPH, MSW, UCSF

What Can Human Brain Imaging Tell Us About Addiction and Recovery from Substance Use? — Dieter Meyerhoff, Dr.rer.nat

HIV Rapid Testing and Counseling in Drug Abuse Treatment Programs in the U.S. — Lisa R. Metsch, PhD, UCSF (protocol CTN-0032)

Substance Use Disorder/Post Traumatic Stress Disorder — Moving from Dichotomous to Dialectic — John Straznickas, MD, UCSF

Promoting Awareness of Motivational Incentives (PAMI) — Michael Shopshire, PhD, UCSF.

Related protocols: CTN-0032