Transcript Strategic Initiative #1

Addressing the Impact of Substance
Abuse on HIV/AIDS Communities: A
SAMHSA Strategy
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director
Center for Substance Abuse Treatment
Substance Abuse & Mental Health Services Administration
U.S. Department of Health & Human Services
2010 Keeping It Real Conference
Baltimore, MD  October 4, 2010
“Each of us must take
responsibility for reducing
our risk of acquiring or
transmitting HIV and for
supporting affected
individuals and
communities. This means
getting tested for HIV and
working to end the stigma
and discrimination people
living with HIV face.”
President Barack Obama
June 27, 2009
3
National HIV/AIDS Strategy
Vision for the National HIV/AIDS Strategy:
“The United States will become a place where new HIV
infections are rare and when they do occur, every
person, regardless of age, gender, race/ethnicity, sexual
orientation, gender identity or socio-economic
circumstance, will have unfettered access to high
quality, life-extending care, free from stigma and
discrimination.”
Source: http://www.whitehouse.gov/administration/eop/onap/nhas
4
“I am honored to assist
the President in achieving
the following goals of the
[National HIV/AIDS]
Strategy: reduce HIV
incidence; increase access
to care and optimize
health outcomes; and
reduce HIV-related health
disparities in the U.S.”
Kathleen Sebelius
Secretary
U.S. Department of Health & Human Services
June 25, 2010
5
SAMHSA: Key Messages
• Behavioral health is
essential to health
• Prevention works
• Treatment is effective
Pamela S. Hyde, J.D.
Administrator, SAMHSA
• People recover from
mental and substance
use disorders
6
SAMHSA’s Role in Improving the Nation’s
Health
 Behavioral health services improve health status and reduce
health care and other costs to society.
 SAMHSA is charged with effectively targeting substance abuse
and mental health services to the people most in need and to
translate research in these areas more effectively and more
rapidly into the general health care system.
 Continued improvement in the delivery and financing of
prevention, treatment and recovery support services provides
a cost effective opportunity to advance and protect the
Nation’s health.
 SAMHSA has identified strategic initiatives to guide us as we
address emerging national trends.
7
SAMHSA’s Strategic Initiatives
 Prevention of Substance Abuse & Mental Illness
 Trauma and Justice
 Military Families – Active, Guard, Reserve, and Veteran
 Health Reform
 Housing and Homelessness
 Jobs and the Economy
 Health Information Technology for Behavioral Health
Providers
 Behavioral Health Workforce – In Primary and Specialty Care
Settings
 Data Quality and Outcomes – Demonstrating Results
 Public Awareness and Support
SAMHSA’s strategic initiatives are continuing to evolve as we
adjust to emerging trends.
8
The Challenge
In 2009, an estimated 22.5 million persons were classified with
substance abuse or dependence.
• 20.9 million of those needing treatment did not receive it.
And, 4.4% of all adults in this country (an estimated 9.8 million
adults, 18 or older) had a serious mental illness in 2008.
• 4.1 million of them did not receive mental health services in
the past year.
These populations are at greatest risk for transmitting and
contracting HIV/AIDS.
They are a critical target for Rapid HIV Testing programs and
need to be a critical target for HIV and substance abuse efforts.
9
Past Month Alcohol Use - 2009
Any Use:
51.9%
(130 million)
Binge Use:
23.7%
(59 million)
Heavy Use:
6.8%
(17 million)
(Current, Binge, and Heavy Use estimates are similar to
those in 2008)
Source: NSDUH 2009
10
Inappropriate Alcohol Use and Risk Behaviors
 Alcohol is a mood altering substance.
 Used alone or with other substances, it can
decrease inhibitions and increase risk behaviors
that can lead to transmission of HIV/AIDS, including:
• Unprotected sex
• Sex with multiple partners
• Increased risk of sexual assault
• Unintended pregnancy or sexually transmitted
diseases
Source CDC: Alcohol-Attributable Deaths Report, Average for United States 2001-2005
11
Past Month Use of Selected Illicit Drugs
among Persons Aged 12 or Older: 2002-2009
Illicit Drugs
Marijuana
Psychotherapeutics
Cocaine
Hallucinogens
10%
Percent Using in Past Month
9%
8.2%
7.9%
8.1%
6.2%
6.2%
6.1%
6.0%
6.0%
5.8%
2.7%
2.7%
2.5%
2.7%
2.9%
2.8%
0.9%
1.0%
0.8%
1.0%
1.0%
8%
7%
8.3%
8.3%
6%
8.0%
8.0%
8.7%
6.1%
6.6%
2.5%
2.8%
5%
4%
3%
2%
1%
0.5%
0%
2002
Source: NSDUH, 2009
0.4%
2003
0.4%
2004
0.4%
2005
0.4%
2006
0.8%
0.4%
2007
0.7%
0.7%
0.5%
0.4%
2008
2009
12
Concurrent Illicit Drug and Alcohol Use
Illicit Drug Use concurrent with Last Alcohol use among Past Month
Alcohol Users aged 12+
No Alcohol in Past
Month
3.7%
Current Alcohol Use (but
not heavy or binge)
5.6%
Binge Alcohol Use (but
not heavy)
17.9%
33.2%
Heavy Alcohol Use
0%
5%
10%
15%
20%
25%
30%
35%
Percentage of Illicit Drug use Concurrent with Past Month Alcohol Use
Source: NSDUH 2009
13
Maryland State Indicators vs.
National Average – 2007/2008
Percent of clients reporting…
Binge Alcohol Use in Past Month
Maryland National Average
2007/2008
22.14%
23.15%
Any Illicit Drug Use in the Past
Month
7.29%
8.14%
Alcohol or Drug Dependence or
Abuse in Past Year
8.91%
9.1%
Needing, but not receiving
treatment for illicit drug use
2.48%
2.5%
Needing, but not receiving
treatment for alcohol use
7.0%
7.0%
Source: NSDUH, 2007-2008
14
Past Month Nonmedical Use of Prescription Drugs
(Psychotherapeutics) among Persons 12+:2002-2009
Pain Relievers
Tranquilizers
Stimulants
Sedatives
Percent Using in Past Month
3%
2%
1.9%
2.1%
2.0%
1.8%
2.1%
1.9%
1.9%
2.1%
2%
1%
1%
0%
0.8%
0.6%
0.2%
2002
Source: NSDUH 2009
0.8%
0.6%
0.7%
0.1%
0.5%
0.1%
2003
2004
0.7%
0.5%
0.1%
2005
0.7%
0.6%
0.2%
2006
0.7%
0.4%
0.7%
0.4%
0.1%
0.1%
2007
2008
0.8%
0.5%
0.1%
2009
15
Past Year Non-medical Use of Pain Relievers –
Maryland – 2007/2008
• Pain relievers account for the highest nonmedical use
of prescription drugs nationally.
• Past year non-medical use of pain relievers in
Maryland was 3.95% compared to 4.8% average use
throughout the U.S.
• In Maryland, young adults (18-25) reported the
highest use: 9.74% -- other age groups reported:
– 5.17% for youths 12-17,
– 2.83% for adults 26+
Source: 2007-2008 NSDH
16
Past Year Perceived Need for and Effort Made to Receive Specialty
Treatment among Persons Aged 12 or Older Needing But Not
Receiving Treatment for Illicit Drug or Alcohol Use: 2009
Did Not Feel
They Needed
Treatment
( 19.8 Million)
94.9%
Felt They Needed
Treatment and Did Not
Make an Effort
(693,000)
3.3%
1.8%
Felt They Needed
Treatment and Did
Make an Effort
(371,000)
20.9 Million Needing But Not Receiving
Treatment for Illicit Drug or Alcohol Use
Source: NSDUH 2009
17
Reasons for Not Receiving Substance Use
Treatment: Persons Aged 12+
Those who Needed & Made the Effort to Get Treatment
But Did Not Receive Specialty Treatment
Did Not Feel the Need for Treatment at the
Time
7.1%
Might Cause Neighbors/Community to Have
Negative Opinion
8.5%
Might Have Negative Effect on Job
8.6%
Had Health Coverage but Did Not Cover
Treatment or Did Not Cover Cost
8.8%
No Transportation/Inconvenient
9.7%
Able to Handle Problem without
Treatment
10.2%
30.5%
Not Ready to Stop Using
No Health Coverage and Could Not Afford
Cost
Source: NSDUH, 2006-2009 combined
36.8%
0%
5%
10%
15%
20%
25%
30%
Percent Reporting Reason
35%
40%
18
Substance Dependence or Abuse among Adults Aged 18 or
Older, by Serious Mental Illness in the Past Year: 2008
% Dependent on or Abusing Substance
Had SMI in the Past Year
Did Not Have SMI in the Past Year
30%
25.2%
25%
19.4%
20%
15%
11.9%
8.3%
10%
5%
7.1%
2.2%
0%
Drug or Alcohol
Dependence or Abuse
Source: SAMHSA NSDUH 2008
Drug Dependence or
Abuse
Alcohol Dependence or
Abuse
19
Consequences of Co-occurring Disorders
• Increased vulnerability to relapse and rehospitalization
• More psychotic symptoms
• Inability to manage finances
• Housing instability and homelessness
• Noncompliance with medications and treatment
• Increased vulnerability to HIV infection and
transmissions, as well as hepatitis
2020
Injection Drug Use and Related Risk Behaviors
Although, according to CDC data, HIV transmission
through injection drug use has remained steady over
the years, the connection between injection drug use
and risk behaviors that can lead to HIV infection remain
a concern.
National Survey on Drug Use and Health (NSDUH) data
indicate that 13% of past year injection drug users
used a needle that they knew or suspected someone
else had used before them.
Less than one-third of users cleaned the needle with
bleach before using.
Source: SAMHSA, National Surveys on Drug Use and Health (NSDUHs) combined 2006-2008
21
Last Use of a Needle to Inject Drugs during Past
Year – 2006 to 2008
Used a Needle That They Knew or
Suspected Someone Else Had Used Before
Them
13.0%
17.7%
Someone Else Used the Needle After Them
51.0%
Reused a Needle They Had Used Before
0%
10%
Source: SAMHSA, National Surveys on Drug Use and Health (NSDUHs) 2006-2008
20%
30%
40%
50%
60%
22
How the Needle Was Obtained the Last Time
used to Inject Drugs – 2006 to 2008
Bought from Pharmacy
12.4%
11.8%
0.5%
Needle Exchange Program
Bought on the Street
Shooting Gallery
52.8%
21.9%
Other
Don't Know/Refused/No
Answer
0.7%
Source: SAMHSA, National Surveys on Drug Use and Health (NSDUHs) 2006-2008
23
Substance Abuse & Risk Behaviors
Injection drug use is only example of the connection
between substance use and abuse and the risk of HIV
infection.
Any psychoactive substance (“Crack” cocaine,
methamphetamines, alcohol & marijuana, etc.) can
reduce inhibitions and impair judgment, increasing
the risk of HIV infection through sexual contact or
injecting drug use.
Treating substance abuse disorders without
addressing risk behaviors leaves patients at a high
risk for HIV infection.
2424
HIV Infection Among Adults & Adolescents by
Sex & Transmission Category - 2008
MALES
1%
4%
FEMALES
1%
15%
15%
9%
72%
Male-to-Male sexual contact
Male-to-Male Sexual Contact & IDU
Other
84%
Injection Drug Use
Heterosexual contact*
*Heterosexual
contact with a
person known
to have, or be
at high risk for,
HIV Infection
Source: CDC, HIV Surveillance - Epidemiology of HIV Infection (through 2008) Data from 37 states and 5 U.S. dependent areas with
confidential name-based HIV reporting since at least January 2006. Maryland is not one of the reporting states.
25
HIV and Minorities
 According to 2008 CDC data, 132 of every 100,000 African
Americans have been diagnosed with HIV infection – the
largest racial/ethnic population.
 Hispanics/Latinos are the second largest population infected,
at 52.3 per 100,000.
 African Americans and Hispanics also make up the 2 largest
percentages of HIV diagnoses attributed to injection drug use
among racial/ethnic populations – 51.9% and 25.8%
respectively.
 In addition, African Americans comprise 68% of those
infected through heterosexual contact, with
Latinos/Hispanics, the second largest group, making up 17%.
Source: SAMHSA, National Surveys on Drug Use and Health (NSDUHs) 2006-2008
26
Racial & Ethnic Disparities
• Even when income, insurance and clinical factors
were taken into account, minorities received inferior
quality services and were less likely to obtain even
routine medical service.
• Minorities are less likely to enter, stay with, or be
satisfied with their treatment.
• Minorities diagnosed with HIV/AIDS experienced
delay in obtaining treatment for their disease and
were less likely to obtain HAART (highly active
antiretroviral therapy) than whites.
Sources: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, Institute of Medicine, 2002; Schmidt, L. et al
(2006) Unequal treatment: Racial and ethnic disparities in alcoholism treatment services, Alcohol Research and Health, 29(1), 49-54;
2727
Minority AIDS Initiative (MAI)
A collaboration of the three SAMHSA Centers:
• the Center for Substance Abuse Treatment (CSAT)
• the Center for Substance Abuse Prevention (CSAP)
• the Center for Mental Health Services (CMHS)
Mission: to promote HIV and hepatitis prevention in
minority communities through programs that:
• Prevent and reduce substance abuse,
• Improve substance abuse treatment, and
• Promote and improve mental health treatment.
28
SAMHSA’s HIV Portfolio
Center for Substance Abuse Treatment (CSAT)
Targeted Capacity HIV (MAI)
HIV Outreach for Substance Users (MAI)
Substance Abuse and Prevention Block Grant HIV Set-Aside
Center for Substance Abuse Prevention (CSAP)
Minority AIDS Initiative (MAI)
Minority Education Initiatives (MEI)
Center for Mental Health Services (CMHS)
Mental Health Services for HIV+ Individuals
29
CSAT TCE/HIV & HIV Outreach
 SAMHSA’s TCE/HIV & HIV Outreach program of 48
grantees is the only national program that addresses
the intersection of HIV and substance abuse
treatment services.
 The program uses a comprehensive approach that
integrates recovery support services into the
treatment program.
 Since 2000, over 132,042 high risk, underserved
populations impacted by HIV have been served.
 The Intake Coverage rate is 83.5%
Source: SAIS, data through 1/22/10
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The Importance of HIV Testing
 The CDC estimates that a quarter of the people living
with HIV are not aware of their infection.
 Cohort studies have demonstrated that many
infected persons decrease behaviors that help
transmit infection to sex or needle-sharing partners
once they are aware of their positive HIV status.
 For that reason, all awarded TCE/HIV & HIV Outreach
FY 2008 grantees are required to administer a HIV
rapid test to 80% of clients served.
Source: CDC, Divisions of HIV/AIDS Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention,
updated 8/3/08
3131
TCE/HIV & HIV Outreach: Demographics
Black or African
American
22.0%
Asian/Pacific Islander
24.9%
1.9%
3.9%
American
Indian/Alaska Native
White
2.0%
*rounded figure. Actual: 0.02%
Source: SAIS, data through 8/27/10
45.2%
Other
Multi-Racial
55.5% of clients are male
43.8% are female
In addition, 32.5% identify as
Hispanic/Latino
3232
TCE-HIV & HIV Outreach: Top 5 Substances
Used
Substance
Alcohol
% Used
43.8%
Marijuana
26.5%
Cocaine
23.0%
Heroin
13.3%
Benzodiazepines
Source: SAIS, data through 08/27/10
3.5%
33
TCE/HIV & HIV Outreach: Outcomes
Clients reporting…
At Intake
6-Month
Follow-up
Difference
No substance use
38.3%
59.9%
 56.2%
Being employed
29.4%
39.4%
 34.0%
Being housed
42.7%
48.8%
 14.4%
No arrests
91.0%
95.9%
 5.3%
Being socially
connected
77.1%
81.0%
 5.0%
Source: SAIS, data through 8/27/10
3434
TCE/HIV & HIV Outreach: Risk Behavior
Outcomes
Clients reporting…
At Intake
6-Month
Follow-up
Difference
Using Injection Drugs
9.6%
4.4%
 54.9%
Unprotected sexual contact
69.9%
62.1%
 11.2%
Unprotected sexual contact with
an HIV+ Individual
4.8%
4.7%
 3.6%
Unprotected sexual contact with
injection drug user
7.5%
5.2%
 29.9%
Unprotected sexual contact with
a high individual
27.1%
18.7%
 31.1%
Source: SAIS data through 08/27/10
3535
TCE/HIV & HIV Outreach: Mental Health
Outcomes
Clients who…
At
Intake
6-Month Difference
Follow-up
Experienced serious depression
48.5%
37.8%
 22.0%
Experienced serious anxiety or tension
48.2%
37.4%
 22.3%
Experienced hallucinations
8.5%
5.4%
 35.9%
Experienced trouble understanding,
concentrating or remembering
36.0%
25.5%
 29.1%
Experienced trouble controlling
violent behavior
15.2%
10.1%
 33.7%
Attempted suicide
2.7%
1.0%
 60.7%
Been prescribed medication for
psychological/emotional problem
21.6%
20.7%
 4.0%
Source: SAIS data through 08/27/10
36
CSAT – SAPT Block Grant Set-Aside
 States with an AIDS case rate of 10 or more per
100,000 individuals (“Designated States”) are
required to set-aside a certain percentage of the
Substance Abuse Prevention & Treatment Block Grant
to establish 1 or more projects for early intervention
services for HIV.
• Maryland is a “Designated State”
 Early intervention services include counseling, HIV
testing, and referral services.
3737
Central East Addiction Technology Transfer
Center
 SAMHSA-funded Addiction Technology Transfer Centers
enhance the quality of addiction treatment and recovery
services within each region by providing policymakers,
providers, consumers and other stakeholders with state-ofthe art information through technology translation and
transfer activities.
 Central East ATTC (CEATTC): The Danya Institute, Inc., Silver
Spring
• Includes the Center for HIV, Hepatitis and Addiction
Training and Technology (CHHATT)
 Through professional development materials and “Keeping It
Real” Conference – CEATTC continues to be an important
resource for raising awareness about addiction-related
HIV/AIDS and Hepatitis.
38
CSAP: Minority AIDS Initiative & Minority
Education Initiative Grants
• Currently, the Center for Substance Abuse Prevention
funds 139 active MAI and MEI grants
• MAI and MEI programs deliver prevention of substance
abuse and HIV/AIDS services to minority populations.
• The selected evidence-based interventions include
education, data collection, coping strategies and other
strategies specific to each grantee organization to
prevent the incidence of substance abuse/HIV.
• Grantees provide HIV testing with pre and post
counseling and referral for HIV treatment through
established linkages of care.
39
SAMHSA-funded HIV Programs in Maryland
 Maryland has two Minority HIV Prevention
grantees:
• Strategic Community Services, Inc., Lanham,
MD., and
• Johns Hopkins University, Baltimore
40
CSAP - Minority Education Initiative (MEI)
 MEI Goal: To increase the number of student tested
for HIV/AIDs by creating normative change on
minority campuses that reduce the risk behaviors
associated with SA/HIV infections and motivate
minority students to seek HIV testing.
 The initiative utilizes peer educators and evidencebased SA/HIV educational programs and
environmental change strategies.
41
CSAP - Minority Education Initiative (MEI)
FY2009 Populations Served
 Target Campus Populations –
• 11 HBCU / 2 HSI / 2 Tribal Colleges
 96 peer educator training sessions
 416 students trained as peer educators
 658 student training sessions conducted
 17,000 students trained
42
CSAP - Minority Education Initiative (MEI)
FY 2009 HIV/AIDS Testing Outcomes




5,986 Students Tested
4,767 Rapid Oral Tests
1,219 Blood Tests
2,419 (40%) of Student Tests were “First Time” Tests
43
CSAP - American Indian/Alaska Native
(AI/AN) HIV/AIDS Initiative
(includes: ICMI - Indian Country Methamphetamine
Initiative)
 Initiative Goal: To increase the capacity of Tribes and
Tribal Colleges to conduct peer educator training and
implement environmental change strategies that will
increase the number of 18-25 year old AI/AN young
adults tested for HIV/AIDs
44
CSAP - Minority HIV/AIDS
Faith-Based Initiative
Goal: To increase the number of minority
young adults tested by HIV/AIDs by
connecting community coalitions with the
faith community and engaging the faith
community in substance abuse and HIV
prevention outreach and awareness
activities, including HIV testing and
counseling.
45
CSAP - Minority HIV/AIDS
Faith-Based Initiative
FY 2009 HIV/AIDS Testing Outcomes
 5,559 HIV Tests
 3,597 (65%) of persons tested were “First Time “
Tests
 8,639 referrals to human and health related service
organizations
 All projects established linkages to collaborators and
partners within the local continuum of care (e.g.,
Health Depts. Ryan White Funded agencies)
46
Hepatitis Prevention
 The Hepatitis Prevention initiative seeks to
demonstrate cost-effective delivery of enhanced
health services to an ethnic minority population
receiving interventions for opioid dependence
within treatment settings with the potential to
increase hepatitis vaccination and testing
47
Hepatitis Prevention (cont’d.)
2009/2010 Program Outcomes:
To date, 21,825 vaccines/test kits, including Twinrix,
Havrix, and Engerix-B have been shipped out for the
combined years.
Total site usage YTD is 8,868 combined (40.6%)
• Twinrix – Of the 20,440 sent, 8604 were used
(42.09%)
• Havrix – Of the 330 sent, 86 were used (26.06%)
• Engerix B – Of the 455 sent, 178 were used
(39.12%)
48
Hepatitis Prevention (cont’d.)
Other Activities include:
• Targeted cities with a higher prevalence of minority
residents and HAV/HBC/HCV
• GSA rates negotiated with the pharmaceutical
company (GlaxoSmithKiline) for a reduced cost - Free
shipping on all vaccine orders
• Conducted site assessments to help determine the
number of vaccines needed by each site given the
patient population
• Accelerated dosing for Twinrix, enabling patients to
complete cycle in 30 days, decreasing waste
• Written documentation accounting for loss or waste
of vaccines or test kits
49
Impact of Affordable Care Act (ACA)
 More people will have insurance coverage
 Medicaid will play a bigger role in MH/SUD than ever
before
 Focus on primary care and coordination with specialty
care
 Major emphasis on home and community based
services and less reliance on institutional care
 Preventing diseases and promoting wellness is a huge
theme
What does this mean for those living with HIV/AIDS?
50
Coverage Under the ACA
 According to the Department of Health & Human
Services, almost 30% of people living with HIV
currently do not have health care coverage.
 Those who do have coverage primarily receive it
through Medicaid, Medicare, and the Ryan White
CARE HIV/AIDS Treatment Extension Action of 2009.
 ACA creates access to health care coverage for 32
million people – expanding Medicaid to 133% FPL estimated 16 million new enrollees
51
Coverage Under the ACA (cont’d.)

Beginning in September 2010, insurers will not be able to deny
coverage to children living with HIV or AIDS.

Insurers also cannot impose lifetime caps on insurance
benefits.

ACA also phases out the Medicare Part D prescription drug
benefit “donut hole,” making HIV/AIDS medications more
affordable.

Health plans are required to cover a number of preventive
services related to behavioral health without cost sharing –
including HIV screening for those at higher risk.
Source: www. Healthcare.gov/news/factsheets/affordable_care_act_people_hiv_aids.html
52
Closing
 Federal initiatives like the National HIV/AIDS
Strategy and new legislation like the Affordable Care
Act are great strides forward in meeting the needs
of those l with substance abuse and mental health
disorders living with HIV/AIDS.
 The provider community needs to continue to
emphasize the importance of early HIV Testing and
the avoidance of risk behaviors -- particularly
among high risk populations.
 Thank you.
5353