# Presentation: 519061

## HIV TESTING IN DRUG ABUSE TREATMENT

**HIV TESTING IN DRUG ABUSE TREATMENT**

**James L. Sorensen, Ph.D.**
**University of California, San Francisco**
** ****and San Francisco General Hospital**
**Presentation at Drug Abuse and Risk Behaviors:  The Evolvig Dynamics of HIV/AIDS, Bethesda, MD **
**May 9, 2007**

**Notes:**
Thank you so much for the opportunity to talk about this issue.  
	- Comment on the conference’s morning and yesterday.
Thank our hosts. 

I want to talk to you about..

## ACKNOWLEDGEMENTS

**Support from NIH/NIDA**: P50DA09253, U10DA15915, R01DA11344, R21DA020369
**Staff & Patients: **San Francisco General Hospital
**Colleagues & Advisors: **Lisa Metsch, Grant Colfax, Jennifer Hettema, Raul Mandler, Jose Szapocznik, Susan Tross, Brad Shapiro

## BACKGROUND

**Changes in HIV Testing & Counseling**
**Technology**
**Simplified collection of samples**
**Quicker results**
**Policy**
**Ethical and Practical Challenges**

## HIV RAPID TEST 

- FDA approved
- Only requires blood from a finger stick or oral fluid from a swab
- Results in 20 minutes
- Does not require laboratory facilities and can be done by drug counselors

- LM slide

## CHANGES IN POLICY

**Changes in HIV Testing & Counseling**
**Technology**
**Finger Stick or Swab**
**Results in 20 minutes**
**Policy**
**Emphasis on benefits to public health **
**More routine testing**
**Less counseling and education**
**Ethical and Practical Challenges**
**Subgroups hard-hit and with less access to care**
**Fears, responsibilities, trust**

## BENEFITS OF WIDESPREAD HIV SCREENING

**Decreases spread of HIV: An HIV diagnosis is associated with reduction in high risk sexual behaviors**
**Improves survival: Linkage to care and treatment**
**Reduces the stigma that is associated with testing based on risk**

- LM slide

## Policy Change:  Offer Routine HIV Testing in Outpatient Health Care Settings

**CDC now recommends offering routine HIV testing to persons regardless of risk factors:**
**Emergency Departments**
**Sexually Transmitted Diseases (STD) Clinics**
**Labor and Delivery**
**Correctional Facilities**
**Offices of Primary Care Physicians**
***Substance Abuse Treatment Clinics***

- LM slide

## ETHICAL AND PRACTICAL ISSUES

**Changes in HIV Testing & Counseling**
**Technology**
**Finger Stick or Swab**
**Results in 20 minutes**
**Policy**
**Emphasis on public health benefits**
**Broadened testing**
**Less counseling and education**
**Ethical and Practical Challenges**
**Subgroups hard-hit, with less access to care**
**Fears, responsibilities, trust**
**Feasibility of screening & treating**

## INFORMATION:Some Available, More Needed

**Desirable impact of HIV testing and counseling on sexual behavior**
**Impact on drug-use risk behaviors is less well understood**

## JH  slide

**Notes:**
HIV testing and counseling has been found to reduce sexual risk behavior.

## Weinhardt et al. (1999). American Journal of Public Health, 89, 1397-1405.

| Variable | Unweighted Effect Size |
| --- | --- |
| Unprotected Intercourse | d = .39 |
| Condom Use | d = .54 |
| No. of Sexual Partners | d = .26 |

- JS  slide

**Notes:**
We have known for a long time that HIV testing reduces sexual risk behaviors.  For example, in meta-analytic review of published research, Weinhardt and colleagues found moderate effect sizes when looking at studies that measured the effects of testing and counseling on unprotected intercourse, use of condoms, and number of partners.

## ?

**?**

- Copenhaver et al. (2006). Journal of Substance Abuse Treatment, 31, 163-171.

- JS  slide

**Notes:**
However, less is known about the effects of testing and counseling on substance use. In another meta-analysis, Copenhaver and colleagues have show that interventions targeting HIV risk behavior generally result in decreased substance use behavior.  However, the interventions these authors tested tended to be longer-term group or individual interventions that focused on education and skill building.  Few studies have specifically examined the effects of testing and post-testing counseling on substance use outcomes.  Of those conducted, several within group studies demonstrate positive effects. 

## ?

**?**

- Calsyn et al. (1992). American Journal of Public Health, 82, 573-576.
- Saxon et al. (1992). Journal of Studies on Alcohol, 53, 611-618.

- JS  slide

**Notes:**
However, of the few randomized trials that have been conducted by Calsyn and Saxon, testing and counseling participants were not shown to have superior drug use outcomes when compared to those who received educational interventions alone.

## ?

**?**

**?**

- JS  slide

**?**

**?**

**Notes:**
Further research is needed to address to this topic. In addition, research is needed to determine the potential mediating role that stimulant use, injection drug use, and alcohol intake may have on high risk sexual behavior. 

## DRUG ABUSE TREATMENT

**Among the nation’s drug abuse treatment programs there is considerable variation in practices related to HIV testing & counseling.**
**In some settings testing is routine.**
**In others, even referral for testing is rare.**

## ARE DRUG TREATMENT PROGRAMS TESTING?

**Fewer than 1/3 of U.S  drug treatment programs offer HIV testing and counseling***
**Less than 1⁄2 of CTN CTPs made HIV testing available either in the CTP, through referral or outsourced ****
_**(But**_** not all studies agree on the %s***)**
**HIV prevalence studies of drug treatment clients yield an HIV prevalence rate of over 1 percent and as high as 28 percent in some places*****

-      *SAMSHA, 2004                   **Brown et al. JSAT, 2006
-  ***Pollack et al, JSAT 2006   ****Murrill et al JUH, 2001

- LM slide

## NEED FOR RESEARCH

**CDC and new guidelines are moving away from HIV counseling at the time of testing**
**Scientific study is needed to evaluate the effectiveness of offering HIV rapid testing + counseling in drug treatment programs**
**Effect on acceptability of HIV testing**
**Effect on risk behaviors**

- LM slide

## CTN STUDY

**The NIDA CTN is developing a protocol to study the impact of**
**Providing rapid HIV testing**
**And counseling in drug abuse treatment programs.**
**	**

## RESEARCH QUESTIONS

**Among persons who attend substance abuse treatment and report being HIV negative or not knowing their status...**
- 	(**1) What is the more effective testing strategy to ensure they get HIV tested and receive their results?**
**	****(2) What is the more effective testing strategy to decrease their risk behaviors?**

- LM slide

## THREE INTERVENTIONS

- Offer on-site HIV rapid testing with Project RESPECT counseling
- Offer on-site HIV rapid testing with minimal counseling
- Offer referral for HIV testing in the community

- LM slide

## CTN 0032 PROTOCOL DEVELOPMENTHIV Rapid Testing and Counseling...Lisa Metsch, Grant Colfax, “et al.”

**Protocol Concept approved by CTN, then by  Dr. Volkow in November, 2006**
**Protocol Development is in progress**
**Informal surveys of CTPs, February – May, 2007 **
**Amount of testing? On site? How recent?**
**Protocol will be reviewed in Summer 2007**

- LM slide

## IN SUMMARY

**Significant changes in HIV testing and counseling**
**Technology, Policy, and Ethical Challenges**
**Study of HIV Rapid Testing and Counseling being planned**
**Need information (need research)**
**Impact on drug use, other risk factors**
**Feasibility of large-scale testing in treatment programs**
**Best-practice solutions to ethical quandries**
**These are Vital Issues in need of attention**

## THANK YOU!

- Contact information:
- 	James.Sorensen@ucsf.edu
- 	415-206-3969