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Clinicians Involved in Screening,
Evaluation, and Treatment of HIV/AIDS,
Hepatitis C Viral Infection, and Sexually
Transmitted Infections in Substance Abuse
Treatment Programs: the National Drug
Abuse Treatment Clinical Trials Network
L.S. Brown, MD, MPH; S. Kritz, MD; J. Rotrosen, MD;
R.J. Goldsmith, MD; E. Bini, MD, MPH; J. Robinson, MEd,
and the NIDA Clinical Trials Network Infections Study
(CTN-0012) Team
Poster Presentation at the Annual Meeting of the American Society on
Addiction Medicine, San Diego, CA – May 5, 2006
ABSTRACT
In the US, users of illicit drugs will largely sustain the epidemics of HIV/AIDS, hepatitis C
(HCV), and sexually transmitted infections (STI). Substance abuse treatment programs can
play a major role in stemming these epidemics. A nationwide study, sponsored by the
National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) examines these three
infection groups from the perspective of administrators and clinicians working in substance
abuse treatment programs, and the states within which they are located. The NIDA CTN has
over 100 Community Treatment Programs (CTPs) with over 300 discreet substance abuse
treatment sites in 17 nodes across the US. Three surveys were developed; one each for
substance abuse treatment program administrators and clinicians, and one for state health
and substance abuse department administrators. This report examines HIV/AIDS, HCV, and
STI-related services provided by substance abuse treatment programs in the NIDA CTN
from the perspective of the clinicians, medical and non-medical, expert and non-expert,
working in these programs. The clinician survey looked at practices, program guidelines,
knowledge, barriers, and opinions of clinicians caring for substance abusers within their
program. Completed surveys were obtained from 1719 of 2207 targeted clinicians working
at 265 substance abuse treatment sites. The breakdown of completed surveys was: (1)
medical expert: 251; (2) medical non-expert: 115; (3) non-medical expert: 522; and (4) nonmedical non-expert: 831. The extensive data obtained from this group of clinicians will be
presented to inform public policy to encourage “best practices” in treating these epidemic
infections.
ACKNOWLEDGEMENTS
• Research Supported by National Institute on Drug
Abuse (NIDA) as part of a Cooperative
Agreement (1U10DA013046) with the NIDA CTN
and other Protocol Team members consisting of:
– Randy Seewald, MD; Cheryl Smith, MD; Frank McCorry,
PhD; Dennis McCarty, PhD; Donald Calsyn, PhD;
Leonard Handelsman, MD; Steve Kipnis, MD
– Patrick McAuliffe, MBA, LADC; Al Hassen, MSW; Karen
Reese, CAC-AD; Sherryl Baker, PhD
– Shirley Irons; Kathlene Tracy, PhD
Drug Abuse Treatment Clinical Trials Network
17 Nodes with 116 Community Treatment Agencies
Reaching into 26 States!
Seattle
Portland
Detroit
New York
City
Denver
Los Angeles
Philadelphia
Baltimore/Richmond
Cincinnati
San Francisco
(CA/AZ Node)
Raleigh/
Durham
Albuquerque
Charleston
Miami
CTN Sites
Boston
New Haven
Long Island
STUDY SITES
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New York Node: New York University, New York, NY
South Carolina Node: Medical University of South Carolina, Charleston, SC
Florida Node: University of Miami, Coral Gables, FL
Great Lakes Node: Wayne State University, Detroit, MI
Ohio Valley Node: University of Cincinnati, Cincinnati, OH
Rocky Mountain Node: University of CO Health Sciences Center, Denver, CO
New England Node: Yale University, New Haven, CT
Delaware Valley Node: University of Pennsylvania, Philadelphia, PA
Mid-Atlantic Node: Johns Hopkins Univ., Baltimore, MD; Medical College
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of Virginia, Richmond
Pacific Region Node: University of California at Los Angeles, CA
Oregon Node: Oregon Health Sciences University, Portland, OR
Washington Node: University of Washington, Seattle, WA
Long Island Node: NY State Psychiatric Institute, New York, NY
North Carolina Node: Duke University, Raleigh/Durham, NC
Southwest Node: University of New Mexico, Albuquerque, NM
Northern New England Node: McLean Hospital, Belmont, MA
California-Arizona Node: University of California at San Francisco, CA
STUDY RATIONALE
• HIV/HCV/STI: major causes of excess
morbidity and mortality in the US
• Substance abuse: a major vehicle for the
transmission of infection
• Scope of, and challenges to identifying,
counseling, and treating persons with
these infections in substance abuse
treatment will assist in developing
effective interventions
IMPORTANT ABREVIATIONS
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HIV = Human Immunodeficiency Virus
AIDS = Acquired Immunodeficiency Syndrome
HCV = Hepatitis C Virus
STI = Sexually Transmitted Infections
CTP = Community Treatment Program
CTN = Clinical Trials Network
SOP = Standard Operating Procedures
IRB = Institutional (Human Subject) Review Board
IMPORTANT DEFINITIONS
• Treatment Program vs. NIDA CTN CTP
• Services Assessed
– Provider Education
– Patient Education
– Patient Risk Assessment
– Patient Counseling
– Patient Medical History & Physical Exam
– Patient Biological Testing
– Patient Treatment
– Patient Monitoring
• Medical vs. Non-Medical Clinical Staff
• ‘Expert’ Clinical Staff
PRIMARY OBJECTIVES
• TO DESCRIBE:
– Range of Infection-Related Services Available
– Clinician Characteristics (training, knowledge,
behavior)
– Opinions
– Perceived Barriers to Providing Infection-Related
Services
• TO EXAMINE ASSOCIATIONS BETWEEN:
– CTPs’ Availability of Selected Infection Services
– Other Constructs Listed Above
DESIGN AND POPULATION
• STUDY DESIGN
– Cross-sectional Survey
– Descriptive & Exploratory
• STUDY POPULATION
– CTP Clinicians
ETHICAL, REGULATORY
& ADMINISTRATIVE
CONSIDERATIONS
• Expedited IRB Approval
• Waiver of Informed Consent
• Training for Node Protocol Managers
STUDY PROCEDURES
• Node Protocol Managers
• Information Sheet In Lieu of Informed
Consent
• Survey Administration
– Paper or Electronic
– Central data acquisition
Clinician Surveys
Statistician
selects
Clinicians from
Treatment
Programs based
on contact
information
provided by
Administrators
Randomization
If non-responder is
a randomly selected
Clinician, the next
eligible
Clinician on the
selection list is sent a
survey
Data Center monitors
the data entry of
Clinicians
Clinician surveys
mailed
Clinician completes
survey online or
mails to Data Center
Data Center
contacts nonresponders after
30 days; flagged
as non-responders
after four weekly
failed attempts
Gathering sessions held
for Clinicians to complete
surveys
Completed surveys
mailed to Data
Center
Data Center contacts
Clinicians to resolve any
data queries
MEASUREMENTS &
ANALYTICAL METHODS
• SAMPLING METHODOLOGY:
At Each CTP …
– All ‘Expert’ Clinicians Designated by the CTP
– 10 randomly sampled ‘Non-Expert’ Clinicians,
in a ratio of Medical:Non-Medical reflecting that of
the CTP’s clinical staff
• ANALYTIC METHODOLOGIES
– ‘Experts’ will be analyzed separately
– Clinicians may decline; next randomly
selected person will be asked to participate
STATISTICAL ELEMENTS
• Sample Size and Precision of the
Estimated Mean
• Analytic Plan
– Descriptive stats for survey variables
– Principal Component or Cluster or Factor
Analysis to group and reduce the number of
variables
– Structural Equation Models to test for
associations
RESULTS
• Surveys Obtained from 1719 Clinicians of
2207 Targeted (78%)
• 831 Non-Medical Non-Experts (48%)
• 115 Medical Non-Experts (7%)
• 522 Non-Medical Experts (30%)
• 251 Medical Experts (15%)
HIV/AIDS, HCV & STI-RELATED SERVICES IN
SUBSTANCE ABUSE TREATMENT PROGRAMS: NIDA CTN
ADMINISTRATOR RESPONSES (N=269)
HIV/AIDS
n (%)
HCV
n (%)
STIs
n (%)
Provider Education
186 (69)
171 (63)
155 (57)
Patient Education
226 (84)
200 (74)
205 (76)
Risk Assessment
224 (89)
194 (77)
195 (77)
History & Physical
Examination
150 (56)
135 (50)
133 (49)
Testing
131 (49)
93 (34)
109 (40)
Counseling
178 (66)
159 (59)
163 (60)
Treatment
103 (38)
78 (29)
92 (34)
Monitoring
117 (43)
95 (35)
105 (39)
SERVICE
CLARITY OF HIV GUIDELINES: % OF
CLINICIANS SCORING GUIDELINES AS CLEAR
NON -
EXPERT
EXP
Non-Med
Medical
Non-Med
Medical
OVERALL
Provider
Education
50%
55%
56%
49%
52%
Patient
Education
57%
60%
66%
54%
60%
Risk
Assessment
57%
54%
65%
59%
60%
History &
Physical Exam
56%
66%
53%
76%
58%
Testing
35%
47%
42%
59%
41%
Counseling
49%
52%
54%
58%
52%
Treatment
43%
55%
46%
55%
47%
Monitoring
39%
42%
38%
51%
41%
SERVICE
ERT
CLARITY OF HCV GUIDELINES: % OF
CLINICIANS SCORING GUIDELINES AS CLEAR
NON -
EXPERT
EXP
Non-Med
Medical
Non-Med
Medical
OVERALL
Provider
Education
42%
53%
43%
45%
43%
Patient
Education
48%
54%
51%
48%
49%
Risk
Assessment
48%
50%
54%
54%
51%
History &
Physical Exam
53%
64%
50%
74%
56%
Testing
32%
44%
37%
54%
37%
Counseling
41%
47%
45%
51%
44%
Treatment
39%
52%
40%
48%
41%
Monitoring
35%
42%
32%
43%
36%
SERVICE
ERT
CLARITY OF STI GUIDELINES: % OF
CLINICIANS SCORING GUIDELINES AS CLEAR
NON -
EXPERT
EXP
Non-Med
Medical
Non-Med
Medical
OVERALL
Provider
Education
40%
50%
41%
40%
41%
Patient
Education
47%
51%
50%
41%
47%
Risk
Assessment
46%
48%
51%
46%
48%
History &
Physical Exam
49%
64%
49%
73%
53%
Testing
28%
42%
35%
50%
35%
Counseling
39%
45%
44%
44%
41%
Treatment
37%
53%
40%
51%
41%
Monitoring
32%
42%
31%
43%
34%
SERVICE
ERT
SUMMARY
• There is…
– substantial variation in the % of programs
offering the various services for a particular
infection group
– consistency in the % of programs offering a
particular service for all three infection groups
SUMMARY
• Clarity of guidelines for the 8 targeted
services is generally about 50% or less for
all three infection groups, with the
following exceptions:
– History & Physical Exam (medical experts and
non-experts) for all three infection groups
– Patient Education and Risk Assessment (nonmedical experts) for HIV
SUMMARY
• Significant opportunities exist to explore
other associations between the HIV/AIDS,
HCV & STI-related services offered and…
– Clinician Characteristics (training, knowledge,
behavior)
– Opinions
– Perceived Barriers to Providing InfectionRelated Services