Integrating Hepatitis Services into Substance Abuse Treatment Programs: New Initiatives from SAMHSA

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and viral hepatitis are important public health concerns for both clients and care providers in substance abuse treatment programs supported by the Substance Abuse and Mental Health Services Administration (SAMHSA). Hepatitis C virus (HCV) is efficiently transmitted percutaneously among injection drug users (IDUs), and HCV infection is common in individuals seeking treatment at SAMHSA-certified Opioid Treatment Programs (OTPs).1 IDUs are also at high risk for infection with hepatitis A virus (HAV) and hepatitis B virus (HBV), both of which are vaccine-preventable.2,3 Because superinfection with HAV or HBV in people with chronic liver disease caused by underlying HCV infection can be particularly severe, vaccination for both HAV and HBV is recommended for people who inject drugs.4–6 Vaccination for both HAV and HBV is recommended for individuals infected with HIV as well.7 In response to this public health issue, SAMHSA has recently undertaken a number of HIV/AIDS and viral hepatitis prevention and control activities, including: (1) ensuring that HIV/AIDS and viral hepatitis are a significant focus in SAMHSA grant programs, as appropriate; (2) increasing the number of SAMHSA grantees that provide HIV testing; (3) collecting and reporting National Outcomes Measures related to the nexus between substance abuse, HIV/AIDS, and hepatitis services provided; and (4) increasing the number of programs serving people with HIV/AIDS and viral hepatitis that apply for review by the National Registry of Evidence-based Programs and Practices.8,9 In fiscal year 2006, SAMHSA's Center for Substance Abuse Treatment (CSAT) supported two specific initiatives related to viral hepatitis prevention and control. These initiatives promote community-based substance abuse treatment services for individuals and families, and work with partners to implement professional and recovery support programs and initiatives that promote best practices. The first initiative, Hepatitis Education and Training in Opioid Treatment Programs, funded the American Association for the Treatment of Opioid Dependence (AATOD) to provide on-site training in prevention, care, and treatment of HCV infection for OTP providers (e.g., physicians, physician assistants, nurses, counselors). With support beginning in September 2004, an expert panel of clinicians and researchers developed a half-day training curriculum. The training describes the latest hepatitis epidemiological data, means of transmission, symptoms of infection, high-risk behaviors, diagnosis and treatment, how to avoid infection and reinfection, decreasing disease progression, identifying liver toxins, and promoting immunizations, as well as when and where to find treatment and interventions recommended when HIV and hepatitis coinfection are present. This education is coupled with pre/post testing to evaluate knowledge gained. Nine peer trainers selected through the Hepatitis C Association teach and facilitate discussion at programs that indicate their interest to AATOD. As of August 2006, 16 states and more than 150 programs have received training through this initiative. After the training has been completed, a contractor independent of the trainers contacts each site to elicit feedback on their satisfaction with the training and suggestions for improvements. The second initiative, Disease Prevention Hepatitis Vaccinations for At-Risk Individuals, is a one-year pilot program to provide free hepatitis A and B vaccination in substance abuse treatment settings. This program recruited substance abuse treatment sites that serve minority populations, including OTPs, office-based sites using buprenorphine (BUP) treatment for opioid dependence, and SAMHSA Minority AIDS Initiative Targeted Capacity Expansion grantees that reported having the capacity to vaccinate clients. As of September 2006, 40 programs located at approximately 75 sites in 20 states were enrolled in this initiative—including 21 methadone clinics, five BUP-certified provider sites, and 14 other grantee programs. This project provided $2 million for a contract to purchase and distribute 43,950 doses of the combined hepatitis A and B vaccine to participating sites to offer free to clients aged 18 years or older.5 Vaccine distribution has been completed. An additional $500,000 was awarded to evaluate the project, including assistance to programs to track vaccine delivery and client coverage with the three-dose vaccine series. The premise of this initiative is that the close follow-up of patients within substance abuse treatment programs facilitates the provision of preventive services, such as vaccination. Several lessons have been learned from this initiative to date: (1) most patients accept hepatitis vaccination (all clinics except one had acceptance rates greater than 90%); (2) there is a greater need for vaccination at substance abuse treatment sites than anticipated (all sites requested more vaccine than available); (3) some substance abuse treatment programs requested and therefore needed technical assistance related to developing and implementing a vaccination protocol, such as the number of doses needed for reasonable protection and how the dosing schedule might be modified for outreach programs and for patients who might not be present for the entire six months needed to complete the vaccination series; and (4) the grant might facilitate developing the necessary organizational relationships between public health agencies and treatment providers to improve preventive and primary-care services for patients in substance abuse treatment programs. These two initiatives are examples of steps that SAMHSA is taking to provide important viral hepatitis prevention services that are recommended for people seeking care in a variety of substance abuse prevention and treatment settings. OTPs and other substance abuse prevention and treatment sites are venues where IDUs who need hepatitis prevention and control services, including counseling and testing for HCV infection and vaccination against hepatitis A and B, can be offered those services. Because OTP clients are seen several times a week to receive medications and counseling, and often remain in treatment for months or years, OTPs are a setting in which clients are more likely to complete vaccination series and receive medical evaluation of positive HCV screening test results than people seen in other public health settings, such as clinics for the treatment of sexually transmitted diseases.10,11 SAMHSA is using the results and feedback from these two initiatives to work more closely with the Centers for Disease Control and Prevention and state Hepatitis C Coordinators to enhance the range of prevention, outreach, and treatment services that might be offered to the described populations at risk. Training OTP providers in the prevention and treatment of HCV infection and offering patients an immediately effective preventive vaccination is the beginning of a more comprehensive viral hepatitis prevention and intervention effort. Based on results of these initiatives, SAMHSA will coordinate additional demonstration initiatives to build the range of preventive services available within substance abuse outreach and treatment programs.