Addiction Health Services Research Conference

Lexington, KYLouise Haynes, MSW

Adoption of HIV Counseling and Testing Following Completion

of Randomized Clinical Trial

““The Bridge”The Bridge”NIDA Clinical Trials NetworkNIDA Clinical Trials Network

2000-20102000-2010

BackgroundBackground

Less than half of community substance abuse treatment Less than half of community substance abuse treatment programs offer HIV testingprograms offer HIV testing

NIDA Clinical Trials Network recently completed a trial NIDA Clinical Trials Network recently completed a trial (CTN0032) comparing strategies for providing testing in (CTN0032) comparing strategies for providing testing in community substance abuse treatment programscommunity substance abuse treatment programs

Report of the experience of one community treatment Report of the experience of one community treatment program that implemented on-site HIV rapid testing program that implemented on-site HIV rapid testing following completion of NIDA clinical trial.following completion of NIDA clinical trial.

Focus on lessons learnedFocus on lessons learned

Community Programs: Challenges to Community Programs: Challenges to Conducting HIV Research and Conducting HIV Research and

Implementing HIV ServicesImplementing HIV Services

Culture changeCulture change

Particularly for psychosocial rehab programs (often 12 Particularly for psychosocial rehab programs (often 12 Step focused) - little past experience in HIV servicesStep focused) - little past experience in HIV services

Psychosocial rehab programs less likely to have medical Psychosocial rehab programs less likely to have medical staff staff

Specialty clinics staffed by counselors without specific Specialty clinics staffed by counselors without specific training in HIV risk reduction strategies. Counselor training in HIV risk reduction strategies. Counselor discomfort with discussion of sexual issues with clientsdiscomfort with discussion of sexual issues with clients

The SettingThe Setting

Lexington Richland Alcohol and Drug Abuse Lexington Richland Alcohol and Drug Abuse Council, Columbia South CarolinaCouncil, Columbia South Carolina

Large publicly-funded, not-for-profit agencyLarge publicly-funded, not-for-profit agency Residential, outpatient, medical detox, DUI, Residential, outpatient, medical detox, DUI,

prevention servicesprevention services Prior to clinical trial, not offering HIV testingPrior to clinical trial, not offering HIV testing Despite SAMHSA initiative SC struggled to bring Despite SAMHSA initiative SC struggled to bring

HIV testing into substance abuse treatment HIV testing into substance abuse treatment programsprograms

3 Phases of Implementation:3 Phases of Implementation: Lessons learned in each phase of Lessons learned in each phase of

implementation implementation

1.1. Clinical trial: enrollment Jan-May 2009 Clinical trial: enrollment Jan-May 2009

2.2. Pilot (detox program): Sept 2009-March Pilot (detox program): Sept 2009-March 20102010

3.3. Full implementation (detox and Full implementation (detox and outpatient): ongoingoutpatient): ongoing

Phase 1Phase 1CTN 0032CTN 0032

Outpatient settingsOutpatient settings Oral swabOral swab RESPECT2 counselingRESPECT2 counseling LRADAC enrolled 115 participants LRADAC enrolled 115 participants

between Jan and May 2009between Jan and May 2009 Follow-up at 1 and 6 monthsFollow-up at 1 and 6 months

Phase 1Phase 1Lessons LearnedLessons Learned

Acceptability of testingAcceptability of testing Value of integrating research practices Value of integrating research practices

with established patient flow in agencywith established patient flow in agency Value of specialty counselors to provide Value of specialty counselors to provide

testing testing

Phase 2Phase 2Pilot in DetoxPilot in Detox

Agency decision to implement HIV Agency decision to implement HIV testing and counselingtesting and counseling

Transition from research to practiceTransition from research to practice1.1. Adaptation of procedures: approach, finger Adaptation of procedures: approach, finger

stick, timing of counseling stick, timing of counseling 2.2. Training of staffTraining of staff

Support of agency managementSupport of agency management Support by research infrastructureSupport by research infrastructure Buy-in of front line staffBuy-in of front line staff

Pilot (Phase 2)Pilot (Phase 2)September 2009 through April 2010September 2009 through April 2010

183 patients tested183 patients tested 62% acceptance rate62% acceptance rate Most common reason for refusal: recently Most common reason for refusal: recently

testedtested

Phase 2Phase 2Lessons LearnedLessons Learned

Acceptability of testing without Acceptability of testing without compensationcompensation

Acceptability of finger stickAcceptability of finger stick Adaptation of research proceduresAdaptation of research procedures

Phase 3Phase 3Full ImplementationFull Implementation

Increased complexity of implementationIncreased complexity of implementation Testing offered in detox and outpatientTesting offered in detox and outpatient Decrease in availability of research staff Decrease in availability of research staff

for testing for testing Need for new source of fundingNeed for new source of funding Health Department grant receivedHealth Department grant received Train additional staffTrain additional staff

Phase 3Phase 3May to Sept 2010May to Sept 2010

Detox: Detox: 52% accepted52% accepted

Outpatient: Outpatient: 18% accepted18% accepted

Total patients tested in Phase 3 (full Total patients tested in Phase 3 (full implementation): 191implementation): 191

Phase 3Phase 3Lesson LearnedLesson Learned

Need for program specific strategyNeed for program specific strategy Need for Quality Assurance Need for Quality Assurance Need for clear chain of commandNeed for clear chain of command Need for stable, adequate fundingNeed for stable, adequate funding Training could be streamlined Training could be streamlined

SummarySummary

Phase 1: randomized clinical trial, enrolled 115, Phase 1: randomized clinical trial, enrolled 115, two arms offered on-site testing, one arm TAUtwo arms offered on-site testing, one arm TAU

Phase 2: pilot in detox, 62% acceptance, 183 Phase 2: pilot in detox, 62% acceptance, 183 testedtested

Phase 3: full implementation, detox and Phase 3: full implementation, detox and outpatient, 52% acceptance in detox, 18% in outpatient, 52% acceptance in detox, 18% in outpatient, 191 testedoutpatient, 191 tested

Post RCT – 374 patients tested on site in 12 Post RCT – 374 patients tested on site in 12 month periodmonth period

Pre RCT – 0 patients tested on site Pre RCT – 0 patients tested on site

Summary Summary CLINICAL CLINICAL Implementation of Implementation of

HIV Risk Reduction InterventionHIV Risk Reduction Intervention

Process of change and acceptance - Agency Process of change and acceptance - Agency participated in multiple HIV risk reduction trialsparticipated in multiple HIV risk reduction trials

RCT implementation was successfulRCT implementation was successful Integrated into routine clinic practicesIntegrated into routine clinic practices Philosophical changesPhilosophical changes Acceptability to clientsAcceptability to clients Leadership supportLeadership support Incentive to agency: peer recognition, financial Incentive to agency: peer recognition, financial

support support ChampionChampion

Participation in a clinical trial gives Participation in a clinical trial gives a community treatment program:a community treatment program:

valuable experience in conducting HIV valuable experience in conducting HIV rapid tests rapid tests

using an HIV risk reduction intervention using an HIV risk reduction intervention

addresses one of the challenges to addresses one of the challenges to implementationimplementation

State Wide ImplementationState Wide Implementation SC has a network of 33 substance abuse treatment SC has a network of 33 substance abuse treatment

providers, contract with single state authority for block providers, contract with single state authority for block grant fundsgrant funds

Since 2006, Goal of state-wide implementation of HIV Since 2006, Goal of state-wide implementation of HIV testing testing

Funding available, but little implementationFunding available, but little implementation State Health Department had little knowledge of SA State Health Department had little knowledge of SA

treatment programs. Complex training requirements.treatment programs. Complex training requirements. Following clinical trial, LRADAC recognized for having Following clinical trial, LRADAC recognized for having

experience and knowledge to promote implementationexperience and knowledge to promote implementation Course developed for counselor certification in HIV Course developed for counselor certification in HIV

testing and counseling, offered at SC School of Alcohol testing and counseling, offered at SC School of Alcohol and Drug Studies at Furman Universityand Drug Studies at Furman University

For more information contact:For more information contact:

Louise Haynes: Louise Haynes: hayneslf@musc.edu hayneslf@musc.edu

ThanksThanks

LRADAC – Beverly Holmes, Study LRADAC – Beverly Holmes, Study Coordinator; Leslie Wilson, Debbie FrancisCoordinator; Leslie Wilson, Debbie Francis

Lisa Metsch, Lauren Gooden, lead team of Lisa Metsch, Lauren Gooden, lead team of CTN0032CTN0032

Kathleen Brady, PI, Southern ConsortiumKathleen Brady, PI, Southern Consortium