Transcript - PAETC | Pacific AIDS Education and Training Center

HIV Testing in Substance Use
Disorder Treatment Settings
Beth Rutkowski, MPH
UCLA Integrated Substance Abuse Programs
(www.uclaisap.org)
Pacific Southwest Addiction Technology Transfer Center
(www.psattc.org)
June 2014
1
Disclosure

I do not have any financial arrangements or
affiliations with commercial sponsors which
have direct interest in the subject matter of HIV
rapid testing in substance use disorder treatment
programs.
2
Special Acknowledgements


Tim Matheson, PhD, San Francisco Department
of Public Health
NIDA/SAMHSA Blending Initiative HIV Rapid
Testing Blending Team
3
Slide 4
What percentage of your
patients/clients are HIV positive?
0%
1.
0%
2.
0%
3.
0%
4.
0%
5.
Less than 10%
10-25%
26-50%
More than 50%
I have no idea
Does your agency offer routine
HIV testing?
0%
1.
0%
2.
Yes
No
Slide 5
Do you ask questions about HIV
status on your standard intake
forms?
0%
1.
0%
2.
Yes
No
Slide 6
Slide 7
What percentage of new HIV/AIDS
cases are associated with a primary
transmission mode of injection drug use?
0%
1.
0%
2.
0%
3.
0%
4.
0%
5.
5%
9%
15%
25%
More than 50%
An Urgent Need


Despite substantial increases in effective HIV
management over the past 15 years, new HIV
cases have appeared in the United States at a
steady rate
In 2009, there were approximately 50,000 new
cases of HIV in 2009.
Nearly 21% of persons who are HIV infected are
unaware of their infection
 The majority of new HIV infections are transmitted
by these individuals

8
Substance Abuse as a Major Factor in
the Transmission of HIV



In 2009, 9% of the new cases of HIV/AIDS
were attributed to transmission through injection
drug use.
Methamphetamine and amphetamine abuse is
widespread and their use is associated with high
risk sexual behaviors.
Studies show that there is a high HIV prevalence
among persons who are in SUD treatment
programs (3% in non-injection drug users to
27% in IDUs)
9
And Yet…

Despite this high prevalence and the
known, well-established link among
substance use, sex risk behaviors, and HIV,
fewer than half of U.S. drug treatment
programs offer HIV testing on-site
10
Advances in
HIV Testing Technology



HIV testing is more readily accessible with faster
results, minimizing loss to follow-up and ensuring that
those who are tested receive their results.
Test results can now be obtained within community
settings in as little as 1-20 minutes.
This provides persons who test positive with
preliminary information about their HIV status,
allowing them to get the care they need to slow the
progression of their disease and to take precautionary
measures and medications that help prevent the spread
of the HIV virus.
11
WHAT DOES THE
RESEARCH SAY?
12
New STD diagnoses
250
225
200
175
150
125
100
75
50
25
0
Project RESPECT Results*:
HIV Prevention Counseling
Effectiveness
211
173
149
107
6 months*
12 months*
(*p<0.05)
RESPECT
Kamb, M.L., et al., JAMA, 1998
Control
13
Results of Project RESPECT
The results of
RESPECT
demonstrated that
client-centered,
RRC is effective in
reducing STD
incidence and risk
behaviors and can
be conducted in
busy public health
clinics.
14
“The benefit of
providing prevention
counseling in
conjunction with HIV
testing is less clear.”
Branson BM, Handsfield HH, Lampe MA, et al; CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant
women in health care settings. MMWR Recomm Rep 2006; 55(RR-14):1-17. Available at:
15
www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.
CTN 0032: HIV Rapid Testing
and Counseling Study


Multisite study to examine the efficacy of on-site
rapid testing and risk-reduction counseling in
increasing the receipt of results and reducing
HIV risk behaviors of substance abuse
treatment program patients.
Conducted in substance abuse treatment
programs representing all different levels of care

Outpatient psychosocial, intensive outpatient,
outpatient narcotic replacement, and residential
programs
Metsch, L.R., et al., AJPH, 2012.
16
Three Study Conditions

Adults who were HIV-negative or whose status
was unknown and who reported no HIV testing
in the last 12 months were assigned randomly to
three study conditions:
Referral for off-site HIV testing;
 On-site rapid HIV testing with brief, risk-reduction
counseling (based on RESPECT-211); or
 On-site rapid testing with verbal information about
testing only

Metsch, L.R., et al., AJPH, 2012.
17
Results



More than 80% of those tested on-site received
their test results as compared with only 18%
who followed through when referred to an
external resource for testing.
On-site rapid HIV testing increased testing rates
and receipt of test results, and identified HIVinfected persons.
Providing brief, client-centered counseling to
high risk drug users did not have an effect on
the sexual risk behaviors of persons who tested
negative.
Metsch, L.R., et al., AJPH, 2012.
18
“There is no additional
benefit from HIV sexual
risk reduction counseling.”
19
NIDA’s Cost Study
Cost of onsite rapid HIV testing with info
only was approximately $36/test offered
 Set-up costs cost each program, on
average, $2,000
 Offering on-site testing with info only
was cost effective compared to referral
off-site ($60,300 quality-adjusted life year
[QALY])

Metsch, L.R., et al., AJPH, 2012.
20
HIV Testing and Counseling in STD
Clinics in the U.S.: An Adaptation of
CTN0032

Primary outcome:


Composite STI incidence at 6-month
follow-up in which a person was
considered positive for STIs if they
were positive on any tested STI
Secondary outcomes:
 Reduction
of sexual risk behaviors
 Reduction
of substance use during
sex
 Cost
and cost-effectiveness of
counseling
Metsch, L.R., et al., JAMA, 2013.
21
Two Testing Strategies
Evaluated in AWARE RCT

Arm 1: On-site HIV rapid testing (via
fingerstick) with brief participant-tailored
prevention counseling
vs.

Arm 2: On-site HIV rapid testing (via
fingerstick) with information only
Metsch, L.R., et al., JAMA, 2013.
22
STD Clinics and
University Counterparts
Allegheny County Health Department
University of Pittsburgh
CPCDS
Duval County Health Department
University of Miami
Los Angeles Gay & Lesbian Center
University of California, San Francisco
Miami-Dade County Health Department
Downtown Miami STD Clinic
University of Miami
Multnomah County Health Department STD
Prevention Program
Oregon Health & Science University
CODA
Public Health - Seattle & King County
Health Department
University of California, San Francisco
Richland County Health Department
Medical University of South Carolina
LRADAC
San Francisco Department of Public Health
University of California, San Francisco
Whitman Walker Clinic
Columbia University
Metsch, L.R., et al., JAMA, 2013.
23
Recruitment & Screening






First sites launched April, 2010
Recruitment took place over 8 months
6,237 screened
5,012 randomized
80.4% of those screened were randomized
Six-month follow-up window
September 21, 2010 – July 15, 2011
Metsch, L.R., et al., JAMA, 2013.
24
Overview of Methods







Recruitment - Minimal eligibility criteria
Rapid HIV testing
STI testing
Behavioral risk assessment
Counseling or information only
Intervention Fidelity and Quality Control
Cost and Cost-Effectiveness Analysis
Metsch, L.R., et al., JAMA, 2013.
25
AWARE Counseling Intervention

Intervention was based on CDC’s RESPECT 2*
counseling model

RESPECT 2: an individually tailored but focused
(counselor directed) HIV prevention counseling format
used in conjunction with rapid HIV testing which aims
to:


Increase the individual’s awareness of personal risk for HIV
Assist the individual in creating an HIV risk reduction plan
*Metcalf, Douglas, Malotte et al; 2005
26
Demographics of Persons
Randomized (n=5012)

Gender




65.6% Male
33.8% Female
0.5% Transgender
Race/Ethnicity




31.7% Non-Hispanic White
45.0% Non-Hispanic Black
15.3% Hispanic
8.0% Other
Metsch, L.R., et al., JAMA, 2013.


28% MSM
Age Range






53.4% 18-29
22.4% 30-39
14.8% 40-49
7.8% 50-59
1.4% 60-69
0.2% >69
27
Baseline Substance Use
Reported Substance Use
%
n/Total
55.6
2767/4974
Any Drug use (excluding marijuana)
28.9
1436/4974
Current Injectors (last six months)
6.1
305/5009
Binge Drinking
16.3
811/4976
Drug Severity: DAST-10 >3
24.8
1243/5012
Binge Drinking or DAST-10 >3
33.4
1674/5012
Any Drug Use
Metsch, L.R., et al., JAMA, 2013.
28
Baseline Substance Use
Substance Use
%
n/Total
Marijuana
45.6
2267/4973
Any Opioid
8.4
418/4973
2.3
113/5007
Tranquilizers/Barbiturates
3.9
196/4973
Stimulants
17.2
853/4973
Methamphetamine/Amphetamine
4.2
207/4973
Any Cocaine
15.2
754/4973
Crack
6.7
335/4973
Powder Cocaine
9.9
494/4973
Club Drugs (X, GHB, Ketamine)
9.2
459/4973
Hallucinogens
3.8
191/4973
IDU Opioid
Metsch, L.R., et al., JAMA, 2013.
29
Baseline STI Prevalence by Gender
MSW (only)
n=1908
MSM
n=1402
Women
n=1702
Total
n=5012
n (%)
n (%)
n (%)
n (%)
Any STI
717(37.6%)
501(35.7%)
917(53.9%)
2135(42.6%)
Any STI (excluding
Syphilis & HSV)
255(13.4%)
286(20.4%)
382(22.4%)
923(18.4%)
Gonorrhea
97(5.1%)
134(9.6%)
51(3.0%)
282(5.6%)
Chlamydia
182(9.5%)
165(11.8%)
145(8.5%)
492(9.8%)
N/A
N/A
245(14.4%)
245(4.9%)
Syphilis
8(0.4%)
47(3.4%)
8(0.5%)
63(1.3%)
Herpes
521(27.3%)
268(19.1%)
754(44.3%)
1543(30.8%)
9(0.5%)
37(2.6%)
6(0.4%)
52(1.0%)
STI
Trichomonas
HIV
Metsch, L.R., et al., JAMA, 2013.
30
Baseline STI Prevalence
by Treatment
Counseling
n=2505
Information Only
n=2507
Total
n=5012
n/Total (%)
n/Total (%)
n/Total (%)
Any STI
1045/2405 (43.5%)
1090/2414 (45.2%)
2135/4819 (44.3%)
Any STI (excluding
Syphilis & HSV)
451/2405 (18.8%)
472/2403 (19.6%)
923/4808 (19.2%)
Gonorrhea
137/2477 (5.5%)
145/2491 (5.8%)
282/4968 (5.7%)
Chlamydia
238/2480 (9.6%)
254/2487 (10.2%)
492/4967 (9.9%)
Trichomonas
126/2492 (5.1%)
119/2495 (4.8%)
245/4987 (4.9%)
Syphilis
28/2475 (1.1%)
35/2495 (1.4%)
63/4970 (1.3%)
Herpes
752/2486 (30.2%)
791/2491 (31.8%)
1543/4977 (31.0%)
29/2502 (1.2%)
23/2504 (0.9%)
52/5006 (1.0%)
STI
HIV
Metsch, L.R., et al., JAMA, 2013.
31
Primary Outcome Analysis –
STI Incidence
Counseling
Information
Only
Overall
aRR
(95% CI)
Full Composite
245/1979
12.4%
222/1986
11.2%
467/3965
11.8%
1.12
(0.95, 1.33)
Less HSV-2 and Syphilis
195/2058
9.5%
184/2054
9.0%
379/4112
9.2%
1.08
(.89, 1.34)
***No significant differences across treatment arms***
Metsch, L.R., et al., JAMA, 2013.
32
Follow-up STI rates by Gender
Gender Group
Information
Counseling
Only
aRR1
MSW (only)
43/764
5.6%
50/755
6.6%
.84
(.51, 1.38)
MSM
103/566
18.2%
71/566
12.5%
1.48
(1.04, 2.10)
Women
104/709
14.7%
104/709
14.8%
1.07
(.80, 1.44)
1
CI is 98.3% (corrected for 3 tests) adjusted for site, race/ethnicity and baseline STI
Metsch, L.R., et al., JAMA, 2013.
33
Substance Use and STIs

Substance use at baseline was associated with
higher rates of STI at follow-up
 Non-MSM
 Marijuana Use: RR=1.34 95% CI(1.09,
1.66)
 MSM
 Stimulant Use: RR=1.88 95% CI(1.41, 2.49)
 Club Drugs: RR=1.84 95% CI(1.35, 2.49)
Metsch, L.R., et al., JAMA, 2013.
34
Self-Reported Sexual Risk
Behavior Results Summary

No difference in rate of overall unprotected sex by
treatment arm

Counseling was associated with about 25% lower
rates of unprotected sex with non-primary partners.
 IRR=.76 95% CI(.61, .94)

Counseling was associated with about 12% lower
rates of total partners.
 IRR=.88 95% CI(.82, .94)
Metsch, L.R., et al., JAMA, 2013.
35
Summary & Conclusion

No effect of counseling in primary analysis

In planned subgroup analysis, significant MSM
interaction: MSM in counseling arm have increased
STIs at follow-up

The intervention decreased reported risk behavior

The trial provided no evidence in support of brief risk
reduction counseling during HIV rapid testing
Metsch, L.R., et al., JAMA, 2013.
36
Other Notes

High rates of substance use in STD settings
suggest that STD clinics are a potential setting
for SBIRT type interventions

Further work is needed to understand potential
harmful effect of counseling for men having sex
with men

Findings are consistent and build on what was
found in CTN 0032
Metsch, L.R., et al., JAMA, 2013.
37
HIV Rapid Testing: Comparisons
across Treatment Modalities

Secondary analysis examined differences in
outcome by program modality
Methadone maintenance programs (3)
 Non-methadone outpatient programs (7)
 Residential programs (3)


Random assignment to:
Off-site referral for HIV risk reduction counseling
(RRC) and testing
 On-site rapid testing with RRC
 On-site rapid testing without RRC

Schwartz et al., JSAT, 2013.
38
HIV Rapid Testing: Comparisons
across Treatment Modalities




Significantly higher rates of HIV testing and feedback
of results by 1 month post-enrollment were seen for
the combined on-site conditions compared to the
offsite condition.
No significant treatment modality or tx modality x
testing condition interaction effects seen
On-site HIV testing is effective across treatment
modalities for achieving high rates of testing and results
feedback.
All programs should be encouraged to adopt or expand
this service.
Schwartz et al., JSAT, 2013.
39
Patient Characteristics and
Availability of Onsite HIV Testing



Data collected in 2008-2009 from 198 program
administrators of agencies participating in the
NIDA CTN
Positive associations between the % of African
American, Hispanic, and IDU patients and the odds
of offering non-rapid onsite HIV testing versus no
onsite testing.
The associations between racial/ethnic composition
and the availability of rapid HIV testing were more
complicated.
Abraham, A.J., et al., JSAT, 2013
40
Patient Characteristics and
Availability of Onsite HIV Testing
These findings suggest that many programs
are responding to the needs of at-risk
populations.
 Programs and their patients may benefit from
greater adoption of rapid testing, which is less
costly and better ensures that patients receive
their results

Abraham, A.J., et al., JSAT, 2013
41
HIV Rapid Testing in Substance
Abuse Treatment Programs: A
NIDA/SAMHSA Blending Initiative
Product
42
NIDA/SAMHSA
Blending Initiative
• The goal is to move important scientific findings
into mainstream addiction treatment
• NIDA and SAMHSA’s Center for Substance Abuse
Treatment began the Blending Initiative in 2001 to
work on a common vision:
– To improve substance use disorder treatment and
accelerate the dissemination of research-based
findings into practice.
43
HIV Rapid Testing Blending Team Members
•
•
•
•
•
•
•
•
•
Louise Haynes, MSW – LRADAC
Christine Higgins, MA – Johns Hopkins University
Tim Matheson, PhD – San Francisco DPH
Lisa Metsch, PhD – University of Miami
Nancy Roget, MS – Mountain West ATTC
Bruce Schackman, PhD – Cornell Medical College
Richard Spence, PhD – Gulf Coast ATTC
Pamela Waters, MEd – Southern Coast ATTC
Mike Wilhelm – Mountain West ATTC
ATTC representative
NIDA/CTN representative
44
The Headline
Offering on-site rapid HIV testing in
substance abuse treatment centers
substantially increased receipt of HIV
test results and identified persons
who were unaware of their HIV
infection
45
What Comprises the HIV Rapid Testing
BT Product?
•
•
•
•
•
Video
Fact Sheet
Resource Guide
Marketing Materials
Implementation Resources
46
Fact Sheet
47
Resource Guide
48
Marketing Materials
49
Implementation Resources
•
•
•
•
•
•
•
SSA Directory
CDC Guidelines
State-Specific Testing Laws
AETC Training and TA
AETC Directory – HIV
Outreach Programs
Agency Budget Worksheet for HIV Rapid
Testing
• Delivering HIV Rapid Test Results: FTCC Video
and Discussion Guide
50
For more information, visit:
www.attcnetwork.org
www.nida.nih.gov/blending
51
Recent Developments:
Testing, Prevention, and
Treatment
52
Home HIV Testing
53
Clearview Stat-Pak
HIV Rapid Test
54
Clearview
Stat-Pak Rapid Test






One-step test
Visual interpretation
Uses blood
Looks for HIV antibodies
Results within 15 minutes
Reactive results can be
read as soon as line is
visible
55
INSTI HIV 1 Rapid Test
56
INSTI Rapid Test

Screening test

Visual interpretation

Looks for HIV antibodies
Uses blood
Results in 1 minute


57
Integrate HIV/HCV Testing!






Add testing to your site; bring in testing agency
At intake, ask about HIV testing and HCV testing
history and status
Ask about HIV/HCV risk behaviors: unprotected
vaginal/anal sex; sharing needles
If HIV+, inquire about HIV care, meds, HIV viral
load
During treatment ask about continued testing/care
During discharge planning, ask about plan for
regular HIV/HCV testing/treatment
79
Slide 80
Beth Rutkowski, MPH
UCLA Integrated Substance Abuse Programs
Pacific Southwest Addiction Technology Transfer
Center
[email protected]
(310) 388-7647
www.uclaisap.org
www.psattc.org
80