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Barriers to Providing Health Services for HIV/AIDS, Hepatitis C Virus Infection, and Sexually Transmitted Infections in Substance Abuse
Treatment Programs in the United States
Edmund J. Bini, MD, MPH1, Steven Kritz, MD2, Lawrence S. Brown, Jr, MD, MPH2,3, Jim Robinson, MEd4, Don Alderson, MS5, John Rotrosen, MD6
1Division of Gastroenterology, VA New York Harbor Healthcare System and New York University School of Medicine, New York, NY; 2Addiction Research and Treatment Corporation, Brooklyn, NY; 3Department of
Public Health, Weill Medical College, Cornell University, New York, NY; 4Nathan Kline Institute, Orangeburg, NY; 5New York State Psychiatric Institute, New York, NY; 6Department of Psychiatry, VA New York Harbor
Healthcare System and New York University School of Medicine, New York, NY
Background & Aim
Methods
Results
Results
• Human immunodeficiency virus (HIV), hepatitis C virus (HCV),
and sexually transmitted infections (STI) are major public health
problems worldwide
• To assess barriers to delivering health services for the 3 targeted
infections, program administrators were provided with a list of 7
barriers and were asked to choose yes or no for each of the 7
barriers to delivering each of the 4 medical and 4 non-medical
services
HIV/AIDS, HCV, and STI Services Offered by the 269
Substance Abuse Programs
Barriers to Providing HIV/AIDS, HCV, and STI Services
Reported by Program Administrators
• The use and abuse of illicit substances is also a major public
health problem, and substance abuse is largely responsible for
sustaining the epidemics of HIV, HCV, and STI in the United
States
• To date, however, the limited multicenter data that are available
demonstrate that HIV/AIDS, HCV, and STI health services are
not universally available in all drug treatment programs
HIV/AIDS
Services
Offered
HCV
Services
Offered
STI Services
Offered
P-Value
Patient medical history and physical exam
59.8%
52.9%
51.6%
0.14
• The treatment program clinician surveys were sent by mail to
2,210 randomly selected clinicians at each of the programs
Patient biological testing
52.4%
36.8%
42.2%
<0.01
Patient treatment
41.5%
30.8%
35.8%
0.04
Patient monitoring
47.4%
37.5%
41.2%
0.08
HIV/AIDS
• The questions that assessed clinician barriers were identical to
the questions in the program administrator survey
Provider education
73.2%
67.3%
60.8%
0.01
Patient education
89.3%
78.4%
80.1%
<0.01
Patient risk assessment
88.5%
75.8%
76.5%
Patient counseling
71.8%
62.4%
63.7%
• The reasons why these services are not offered are unknown
• The primary aim of this study was to determine barriers to
offering health services for HIV/AIDS, HCV, and STI within
substance abuse treatment programs in the United States
Medical Services
Patient
Medical
History and
Physical
Exam
Patient
Biological
Testing
Patient
Treatment
Patient
Monitoring
Provider
Education
Patient
Education
Patient Risk
Assessment
Patient
Counseling
Government
regulations
11.8%
16.0%
17.9%
14.3%
9.4%
9.1%
5.8%
10.5%
Treatment program
policies
14.2%
18.3%
19.2%
18.4%
8.2%
7.4%
7.1%
11.3%
<0.01
0.06
Staff training
27.0%
29.2%
34.9%
34.0%
41.5%
39.4%
32.8%
39.5%
Funding
56.7%
63.8%
70.4%
64.9%
64.2%
58.4%
47.9%
62.0%
Patient/client health
insurance benefits
48.3%
52.1%
58.6%
53.8%
34.6%
42.3%
35.8%
51.9%
Patient/client
acceptance
32.8%
37.3%
41.4%
39.3%
17.0%
38.6%
33.8%
43.3%
Staff acceptance
11.0%
16.5%
14.3%
16.0%
13.3%
13.0%
11.3%
15.9%
Other barriers
4.8%
3.4%
8.2%
6.5%
3.4%
5.4%
2.1%
6.7%
Government
regulations
13.2%
14.2%
15.7%
16.3%
7.4%
7.0%
5.7%
8.7%
Treatment program
policies
11.8%
20.7%
22.9%
20.6%
8.3%
7.0%
8.3%
12.3%
Staff training
27.6%
31.7%
39.6%
36.8%
41.3%
44.7%
36.2%
43.9%
Funding
55.3%
65.1%
71.7%
63.4%
65.2%
61.5%
48.5%
60.3%
Patient/client health
insurance benefits
49.1%
57.1%
59.4%
53.9%
34.3%
42.1%
35.6%
48.7%
3.0
Patient/client
acceptance
33.8%
39.8%
47.8%
43.7%
13.0%
33.8%
31.0%
39.7%
2.0
Staff acceptance
11.8%
16.4%
17.0%
17.5%
12.2%
12.4%
12.7%
14.2%
Other barriers
8.3%
10.3%
8.8%
8.6%
6.9%
7.6%
4.1%
8.2%
Government
regulations
11.7%
14.7%
14.2%
12.3%
8.1%
10.3%
8.2%
10.8%
Treatment program
policies
13.7%
20.3%
16.4%
17.8%
10.2%
13.2%
9.4%
12.0%
Staff training
31.8%
31.9%
36.1%
31.9%
42.2%
45.1%
33.8%
41.3%
Funding
53.4%
59.2%
63.8%
57.8%
62.3%
59.7%
50.8%
59.0%
Patient/client health
insurance benefits
47.4%
53.0%
55.2%
50.4%
32.3%
41.6%
36.4%
49.8%
Patient/client
acceptance
33.8%
36.2%
37.4%
39.5%
14.8%
34.8%
35.5%
40.9%
Staff acceptance
11.7%
16.5%
16.0%
15.8%
13.3%
14.2%
10.3%
15.5%
Other barriers
6.6%
6.6%
6.6%
6.5%
6.7%
4.8%
5.2%
7.9%
Results
Median Number of the 8 Health Services Offered for HIV/AIDS,
HCV, and STI
• Completed surveys were received from
HCV
7.0
 1,723 of the 2,210 clinicians (78.0%)
P <0.01
6.0
5.0
Characteristics of the 269 Substance Abuse Programs
4.0
Characteristic
Percent
• The target population for this study included treatment program
administrators (program directors or managers) and treatment
program clinicians in all substance abuse treatment programs
within the National Drug Abuse Treatment Clinical Trials Network
(CTN) in the United States
Corporate structure
Private not-for-profit
Private for-profit
Government
Other
Nature of the program
Hospital/Medical School/University
Mental Health/Family/Child Services Center
Free-Standing
Other
13.9%
12.7%
60.7%
12.7%
• The CTN includes a large number of treatment programs whose
mission is to improve the quality of drug abuse treatment
throughout the country using evidence-based medicine and
science as the vehicle
Largest source of revenue
County/local grants
State funds
Medicaid
Federal grants
Other
17.2%
39.3%
17.6%
12.6%
13.4%
• The treatment program administrator surveys were sent by mail
to each of the administrators of the 319 treatment programs
within the CTN
• This comprehensive survey assessed the structure of the
treatment program, staffing, funding, characteristics of the
patients enrolled in the program, services offered for HIV/AIDS,
HCV, and STI, and barriers to offering services for these
infections
• For each of the 3 infections, we assessed the availability of 8
health services (offered either on-site or by contractual
agreement with another provider), including
 4 medical services (medical history/physical examination,
biological testing, medical treatment, medical monitoring)
 4 non-medical services (provider education, patient
education, patient risk assessment, patient counseling)
Barriers to Providing
Services
8.0
 269 of the 319 program administrators (84.3%)
Methods
Non-Medical Services
78.7%
5.6%
13.4%
2.2%
1.0
Addiction services offered
Inpatient or residential services
Outpatient pharmacotherapy
Other outpatient services
Outreach & support services
55.0%
36.8%
80.2%
87.6%
Medical staff (MD, PA, NP, RN, LPN, etc.)
0
1–3
4 or more
21.1%
36.4%
42.5%
Non-medical staff
0–7
8 – 17
18 or more
Current patient census
0
1 – 500
501 – 1,000
1,000 or more
30.3%
45.2%
24.5%
2.0%
56.9%
20.4%
20.8%
Percent of patients infected with HIV
0
1 – 10
11 – 20
21 or more
12.4%
65.7%
12.4%
9.6%
Percent of patients infected with HCV
0
1 – 10
11 – 20
21 or more
9.2%
30.1%
12.1%
48.6%
Percent of patients infected with STI
0
1 – 10
11 – 20
21 or more
8.3%
57.5%
15.0%
19.2%
STI
0.0
HIV/AIDS
HCV
STI
Proportion of Programs That Did Not Offer Any of the 4
Medical or 4 Non-Medical Services for HIV/AIDS, HCV, and STI
No Medical Services
No Non-Medical Services
100.0%
100.0%
90.0%
90.0%
80.0%
P <0.01
P <0.01
80.0%
70.0%
70.0%
60.0%
60.0%
50.0%
50.0%
40.0%
40.0%
30.0%
30.0%
20.0%
20.0%
10.0%
10.0%
0.0%
References
Conclusions
0.0%
HIV/AIDS
HCV
STI
HIV/AIDS
HCV
STI
• Health service delivery for HIV/AIDS, HCV, and STI is less than
optimal in drug treatment programs in the United States
• The frequency and types of barriers reported by program
administrators and clinicians were similar
• Only the barriers reported by the program administrators are
presented
• There are numerous barriers to providing these services
• Public health interventions to overcome barriers to care afford
an opportunity to enhance treatment and prevention of these
infections