Role of substance abuse treatment 1
The Role of Substance Abuse Treatment in Reducing HIV Risk Behaviors
David C. Thompson
Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration, Rockville, Maryland, U.S.
Miriam E. Phields, PhD
ACS/Birch & Davis, Falls Church, Virginia, U.S.
Robert Atanda, PhD
ACS/Birch & Davis, Falls Church, Virginia, U.S.
Kevin Mulvey, PhD
Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration, Rockville, Maryland, U.S.
Summary To reduce the spread of HIV/AIDS among racial/ethnic minorities, the Congressional Black Caucus Minority AIDS Initiative provided resources to the Substance Abuse and Mental Health Administration’s Center for Substance Abuse Treatment to fund 128 community-based substance abuse treatment and outreach programs to provide drug treatment and HIV services. This study investigated changes (from baseline to six months post baseline) in self-reported HIV risk behavior among clients (N = 3,137) receiving substance abuse treatment and/or HIV services. At baseline, HIV risk behaviors, such as sharing injection equipment and unprotected sex with HIV+ and injection drug using partners, were reported. Significant reductions in some HIV risk behaviors were found. To reduce the spread of HIV/AIDS in drug and alcohol using populations, HIV prevention and related services can be successfully integrated with substance abuse services (i.e., mobile HIV counseling and testing, drop-in centers for pre-treatment clients, primary health care) by using community-based agencies and peer educators.
Preliminary Draft Comments or questions regarding this manuscript should be directed to: David C. Thompson (dthompso@samhsa.gov) Center for Substance Abuse Treatment 5600 Fishers Lane, Rockwall II, Suite 740 Rockville, MD 20852
Poster presented at the XIV International AIDS Conference, Barcelona, Spain, July 11, 2002.
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The Role of Substance Abuse Treatment in Reducing HIV Risk Behaviors Introduction In 1998 a group of concerned African American community leaders met to review the latest surveillance data on AIDS in the U.S. They reviewed the staggering increases that were being noted in their communities while overall AIDS rates in the country were leveling off and even decreasing among certain population groups, especially Caucasian men who have sex with men. The rates were so disproportionate that they agreed to take action. They demanded a meeting with the U.S. Centers for Disease Control and Prevention (CDC) and were granted a meeting in the late summer of 1998. After reviewing the data, they demanded that the CDC take the lead in recommending that the Secretary of Health and Human Services, Dr. Donna Shalala declare a health emergency declaration for African American communities. When the CDC did not take immediate action, they took their case directly to the U.S. Congress. Thus was born the Congressional Black Caucus Minority AIDS Initiative designed to reduce the spread of HIV/AIDS among racial and ethnic minorities. The initiative originally provided $50.0 million to the U.S. Department of Health and Human Services of which $18.0 million was made available to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Substance Abuse Treatment (CSAT) to fund 60 community-based substance abuse treatment and outreach programs to provide alcohol and drug treatment and HIV services. At President Clinton’s direction, Secretary Shalala declared the AIDS epidemic in minority communities a “crisis,” not the emergency that the group had lobbied for, but still more than had been done in the past. The ambitious goals of the initiative were to: Direct Federal funds to follow the epidemiological trends of the HIV epidemic; Reduce further transmission of HIV/AIDS and promote early intervention and treatment; Promote widespread understanding among African Americans that disease management and treatment can increase the length and quality of life for people living with HIV/AIDS; Address the longstanding disparities in the allocation of HIV prevention resources among African American communities; Build and sustain the organizational infrastructure and capacity of African American community-based organizations and institutions; Ensure access to state of the art HIV clinical care and drug therapies to African Americans living with HIV/AIDS; and Develop and expand sound policies and programs that address the intersecting epidemics of HIV, sexually transmitted diseases (STDs), and substance abuse.
When the Congressional Black Caucus was later joined by the Congressional Hispanic Caucus, the initiative was renamed the National Minority AIDS Initiative to include all minority populations in the U.S. disproportionately affected by HIV/AIDS. Selected to reach communities that had traditionally been marginalized for HIV/AIDS prevention and treatment programs, the community-based programs also had the advantage of being physically located in areas disproportionately impacted by the HIV epidemic. Finally, these agencies had the ability to provide culturally appropriate interventions that addressed language, community involvement, and the provision of services and information by peer field
Poster presented at the XIV International AIDS Conference, Barcelona, Spain, July 11, 2002.
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staff. Over the following three years SAMHSA/CSAT’s program has grown to fund 128 projects in every region of the U.S. A parallel event also began to impact the way that the U.S. Department of Health and Human Services conducted business with its programs and grantees. In 1993 the U.S. Congress passed the Government Performance and Results Act (GPRA), requiring all agencies to report outcome data. SAMHSA/CSAT operationalized the GPRA legislation by requiring it’s grantees to report outcome data via its Client Outcome Measures tool at three points of contact. In order to gather information about the changes in the client’s behavior, health, and living conditions before and after the program interventions, programs/grantees were required to collect baseline data at intake/admission and then to collect longitudinal outcome data 6 months and 12 months after the baseline data were collected. The purpose of this study was to examine changes in the clients’ substance use and sexual risk behaviors before and after the provision of substance abuse treatment and HIV services (i.e., baseline and six months post baseline measures) by the SAMHSA/CSAT-funded programs. Method Participants The data set was reduced from a total of 10,723 clients who received substance abuse treatment and/or HIV services from community-based providers funded by SAMHSA/CSAT and who were administered the baseline measures. Inclusion criteria were clients who completed interviews at baseline and six months later and resulted in a total sample of 3,137. Two samples were used from this pool of participants. The first sample consisted of 1,935 clients who received substance abuse treatment and HIV services from the community-based programs nationwide. The majority of participants were female (66.0%). In general, clients reported their race as African American/Black (58.9%), “other” (22.1%), and White (12.6%). In a separate question, one quarter of participants identified themselves as Hispanic/Latino. Most of the clients ranged in age from 30 to 49 years old (62.0%). The second sample consisted of 1,202 clients who received outreach and HIV services (e.g., HIV/STD/TB screening, HIV prevention education and counseling) from community-based service providers located nationwide. Contrary to the first sample, the majority of the second sample was male (61.8%). Slightly more than half of the participants reported their race as African American/Black (55.9%). Less than a quarter reported their race as White (22.1%) or as “other” (20.3%). Nearly half of the participants (45.8%) identified themselves as Hispanic/Latino. As compared to the first sample, slightly more clients ranged in age from 30 to 49 years (68.3%).
Poster presented at the XIV International AIDS Conference, Barcelona, Spain, July 11, 2002.
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Instruments Government Performance and Results Act (GPRA) Client Outcome Measures for the Center for Substance Abuse Treatment (SAMHSA/CSAT). Developed by the Substance Abuse and Mental Health Administration (SAMHSA) of the United States Department of Health and Human Services for grantee reporting purposes, the GPRA Client Outcome Measures includes items from modified from the Addiction Severity Index and the McKinney Homeless Program tool. Six sections assess self-reported a) alcohol and drug use, b) family and living conditions c) education, employment, and income, d) crime and criminal justice status, e) mental and physical health problems and treatment, and f) demographic information. The demographic items and the drug use items associated with HIV risk were used the present study. Targeted Capacity Expansion HIV Cross-site Assessment Tool. Developed by the SAMHSA/CSAT HIV grantees, the Targeted Capacity Expansion HIV Cross-site Assessment Tool measures self-reported information in four domains a) lifetime alcohol and other drug use related HIV risk behaviors, b) sexual risk behaviors, c) other risk behaviors (e.g., tattoos and body piercing), and d) social and cultural factors. The sexual risk behavior items as well as the drug use behavior items (e.g., injection, sharing injection equipment) were used in the present study to assess HIV risk behaviors. HIV Outreach Cross-site Cluster Evaluation Tool. Developed by the SAMHSA/CSAT outreach grantees, the HIV Outreach Cross-site Cluster Evaluation Tool consists of five items that measure self-reported a) protected sexual contact, b) drug injection, c) sharing injection equipment, d) attempt to get alcohol or drug treatment, and e) success in getting treatment. The first three items related to HIV risk were used in this study. Procedure Although 12 month data was collected, this study examined only baseline and six month data. In this study, the interviews were conducted at a total of 63 community-based sites. The first sample (n = 1,935), participants who received substance abuse treatment and HIV services, was administered the GPRA Client Outcome Measures and the TCE HIV Cross-site Assessment Tool. The second sample (n = 1,202), participants who received outreach and HIV services, was administered the GPRA Client Outcome Measures and the HIV Outreach Cross-site Cluster Evaluation Tool. Six-month data collection was attempted regardless of client discharge or completion status. Results Among the participants in the first sample who received substance abuse treatment and HIV services, paired t-tests were used to examine changes in HIV risk behaviors at baseline and six months later. Comparisons between baseline and six month injection equipment sharing behaviors in the past 30 days showed small significant reductions in the frequency of sharing needles/syringes (M = 1.32, SD = 7.72, t (184) = 2.33, p < .05) and water for injection (M = 1.78, SD = 11.17, t (180) = 2.15, p < .05), but were not found for frequency of sharing cookers nor cotton. Moreover, comparisons in sexual risk behaviors in the past 30 days at baseline and six months indicated small significant reductions in the
Poster presented at the XIV International AIDS Conference, Barcelona, Spain, July 11, 2002.
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number of sexual partners ( = 0.46, SD = 6.87, t (1534) = 2.62, p < .01) and the number of M unprotected sexual contacts with injection drug users (M = 0.52, SD = 4.55, t (360) = 2.19, p < .05). Significant reductions were not found for number of sexual contacts nor unprotected sexual contacts with a main partner, other partners, a person with HIV/AIDS, or an injection drug user in the past 30 days. Among the participants in the second sample who received outreach and HIV services, chisquare statistic was used to examine the sexual risk behaviors and risk behaviors associated with sharing injection equipment. Significant differences between baseline and six month data were found for frequency of use of a condom or latex barrier during sexual contact in the past 30 days (?2(16, N = 376) = 91.38, p <.001). At the six month point, fewer clients at baseline (44.4%) as compared to six months (57.4%) reported never using a condom or latex barrier during sexual contact in the past 30 days, while a greater number of clients reported always using condoms or latex barrier at six months (29.8%), as compared to baseline reports (16.5%). Comparison of baseline and six month data did not yield significant differences for frequency of using syringe, cooker, cotton, or water for injection that had been used by someone else (?2(16, N = 233) = 23.75, p = .10). Significant reduction (M = 54.02, SD = 106.05, t (246) = 8.01, p < .001) was found for frequency of injecting drugs in the past 30 days at baseline (M = 122.57. SD = 114.17) and at six months (M = 68.55, SD = 85.15). Conclusions The findings of this study suggest that the provision of substance abuse treatment and HIV services can play an important role in reducing injection-related and sexual HIV risk behaviors among alcohol and drug users. That all HIV risk behaviors investigated were not significantly reduced indicates that further research on the risk behaviors less likely to be reduced is warranted. Nonetheless, clients appeared to benefit from an integrated HIV services and substance abuse treatment exhibited reductions in HIV risk behaviors. Integrated systems of services and care can play an important role in reducing the spread of HIV/AIDS in drug and alcohol using populations. HIV prevention and related services can be successfully integrated with substance abuse services (i.e., mobile HIV counseling and testing, drop-in centers for pre-treatment clients, primary health care) by using community-based agencies and peer educators.
Poster presented at the XIV International AIDS Conference, Barcelona, Spain, July 11, 2002.