2. Disparities in Infection-Related Services in Substance Abuse Treatment Programs for Underserved Populations L.S. Brown, MD, MPH; S. Kritz, MD; E. Bini, MD, MPH; J. Robinson, MEd, D. Alderson, MS; J. Rotrosen, MD and the NIDA Clinical Trials Network Infections Study (CTN- 0012) Team Addiction Research & Treatment Corp, Brooklyn, NY; NYU School of Medicine and VA Hospital, NY, NY; Nathan Kline Institute, Orangeburg, NY; and NYS Psychiatric Institute, NY, NY

3. Drug Abuse Treatment Clinical Trials Network Philadelphia Portland Los Angeles Charleston Miami Cincinnati Denver CTN Study Sites Seattle Raleigh/ Durham Long Island Boston San Francisco (CA/AZ Node) New York City Detroit Albuquerque Baltimore/Richmond New Haven 17 Nodes with 116 Community Treatment Agencies Reaching into 26 States!

4. ACKNOWLEDGEMENTS Research Supported by the National Institute on Drug Abuse (NIDA) as part of a Cooperative Agreement (1U10DA013046) with the NIDA Clinical Trial Network Research Supported by the National Institute on Drug Abuse (NIDA) as part of a Cooperative Agreement (1U10DA013046) with the NIDA Clinical Trial Network This is the 3 rd report from this study. The others: This is the 3 rd report from this study. The others: –Brown LS, et. al. Characteristics of substance abuse treatment programs providing services for HIV/AIDS, hepatitis C virus infection, and sexually transmitted infections: The National Drug Abuse Treatment Clinical Trials Network. J. Substance Abuse Treatment, 2006;30: 315-321. –Brown LS, et. al. Health services for HIV/AIDS, hepatitis C virus, and sexually transmitted infections in substance abuse treatment programs. Public Health Reports (in press). There are no financial interests or disclosures to report for any authors involved in this project There are no financial interests or disclosures to report for any authors involved in this project

5. RATIONALE: THIS REPORT HIV/HCV/STI: major causes of excess morbidity and mortality in the US HIV/HCV/STI: major causes of excess morbidity and mortality in the US Substance use: a major vehicle for the transmission of infection Substance use: a major vehicle for the transmission of infection Women and Minorities: over-represented in the consequences of substance use and these infections. Women and Minorities: over-represented in the consequences of substance use and these infections.

6. OBJECTIVES: THIS REPORT TO DESCRIBE: TO DESCRIBE: –Range of Infection-Related Services Available –Treatment Program Characteristics –Patient Characteristics –Perceived Barriers to Providing Infection-Related Services TO EXAMINE ASSOCIATIONS BETWEEN: TO EXAMINE ASSOCIATIONS BETWEEN: –Availability of Addiction Services Targeted for Women or Minorities and: Treatment Program and Patient Characteristics Treatment Program and Patient Characteristics Availability of Infection-Related Services Availability of Infection-Related Services Perceived Barriers to Providing Infection-Related Services Perceived Barriers to Providing Infection-Related Services

7. STUDY POPULATION 319 TREATMENT PROGRAM ADMINISTRATORS FROM 116 AGENCIES IN NIDA CTN 319 TREATMENT PROGRAM ADMINISTRATORS FROM 116 AGENCIES IN NIDA CTN 269 PROGRAMS (84%) RETURNED 269 PROGRAMS (84%) RETURNED ETHICAL REGULATORY ETHICAL REGULATORY –Expedited IRB Review –Waiver of Informed Consent

8. STUDY DESIGN DESCRIPTIVE & OBSERVATIONAL DESCRIPTIVE & OBSERVATIONAL CROSS-SECTIONAL SURVEY (Selected Items) CROSS-SECTIONAL SURVEY (Selected Items) –Treatment Program & Patient Characteristics –Availability of 7 Infection-related Services: Education, Risk Assessment, Counseling, Medical History & Physical Exam, Biological Testing, Medical Treatment, Medical Monitoring –For 3 Infections: HIV, HCV, STI –8 Perceived Barriers to Providing Infection- Related Services: government regulations, treatment program policies, staff training, funding, patient health insurance, patient acceptance, staff acceptance, or other

9. STATISTICAL ANALYSIS Summary of Number (proportion) of respondents providing various answers Summary of Number (proportion) of respondents providing various answers Cross-tabulations of Availability of Addiction Services for Women or a Minority Population Group and: Cross-tabulations of Availability of Addiction Services for Women or a Minority Population Group and: Treatment Program & Patient Characteristics Treatment Program & Patient Characteristics Availability of 7 Infection-related Services for each of 3 Infections Availability of 7 Infection-related Services for each of 3 Infections Perceived Barriers to Providing the Infection- related Services Perceived Barriers to Providing the Infection- related Services Chi-square (Fisher’s Exact) Test with Odds ratios and 95% Confidence Intervals Chi-square (Fisher’s Exact) Test with Odds ratios and 95% Confidence Intervals

10. SUBSTANCE ABUSE TREATMENT PROGRAMS (N=269) OFFERING ADDICTION SERVICES FOR VARIOUS POPULATIONS POPULATION PERCENT OF PROGRAMS WITH TAILORED SERVICES Women73.9 African Americans37.5 Latinos43.3 American Indian/Alaskan Native19.4 Asian18.6 Hawaiian/Pacific Islander15.7 No Women or Special Population20.1 At Least One Special Population Group79.9 One Special Population Group34.5 2-3 Special Population Groups25.3 4 or More Special Population Groups20.1

11. TYPES OF HEALTH SERVICES WOMEN AFRICAN AMERICANSLATINOAMERICANS AMERICAN INDIANS/ ALASKAN NATIVES ASIANS HAWAIIANS/ PACIFIC ISLANDERS WithWithoutWithWithoutWithWithoutWithWithoutWithWithoutWithWithout n=190n=79n=91n=171n=106n=163n=46n=223n=44n=225n=37n=232 Education92%85%95%88%94%89%95%91%98%90%95%90% Risk Assessment90%85%92%88%91%88%95%88%93%88%92%89% Counseling75%64%86% 64%* 82% 66%* 84%70%82%71%81%70% Medical History & Physical Exam62%57%72% 55%* 66%57%65%61%60%61%61%61% Biological Testing54%51%60%48%57%50%52%53%45%54%47%54% Medical Treatment45%33%64% 30%# 58% 33%# 56%40%56%40%53%41% Medical Monitoring53%37%67% 38%# 63% 39%# 60%47%58%47%60%47% Percent of Treatment Programs Providing HIV-Related Health Services With and Without Addiction Services Designed For: * p<0.05; # p<0.001

12. TYPES OF HEALTH SERVICES WOMEN AFRICAN AMERICANSLATINOAMERICANS AMERICAN INDIANS/ ALASKAN NATIVES ASIANS HAWAIIANS/ PACIFIC ISLANDERS WithWithoutWithWithoutWithWithoutWithWithoutWithWithoutWithWithout n=190n=79n=91n=171n=106n=163n=46n=223n=44n=225n=37n=232 Education82%74%84%78%81%79%89%79%86%79%83%79% Risk Assessment81% 66%* 82%75%81%75%86%76%84%76%78%77% Counseling66%56%76% 56%# 70%58%77% 60%* 74%61%69%62% Medical History & Physical Exam55%49%65% 47%# 59%48%63%52%58%53%58%53% Biological Testing37%38%49% 30%# 43%33%48%35%37%37%36%37% Medical Treatment32%28%51% 21%# 42% 23%# 48% 28%* 47% 44%29% Medical Monitoring39%34%56% 29%# 49% 31%* 57% 35%* 51%36%47%37% Percent of Treatment Programs Providing HCV-Related Health Services With and Without Addiction Services Designed For: * p<0.05; # p<0.001

13. TYPES OF HEALTH SERVICES WOMEN AFRICAN AMERICANSLATINOAMERICANS AMERICAN INDIANS/ ALASKAN NATIVES ASIANS HAWAIIANS/ PACIFIC ISLANDERS WithWithoutWithWithoutWithWithoutWithWithoutWithWithoutWithWithout n=190n=79n=91n=171n=106n=163n=46n=223n=44n=225n=37n=232 Education82%76%89% 77%* 87% 76%* 87%81%84%81%86%81% Risk Assessment79%71%86% 73%* 83%74%84%77%86%77%84%77% Counseling66%60%81% 54%# 73% 57%* 76%61%79% 61%* 72%63% Medical History & Physical Exam54%48%65% 44%# 59%47%56%52%55%52%51%52% Biological Testing44%39%56% 35%# 48%39%50%42%55%40%41%43% Medical Treatment38%29%57% 24%# 49% 28%# 53%33%55% 32%* 49%34% Medical Monitoring44%36%63% 31%# 55% 33%# 58%39%58% 39%* 56%40% Percent of Treatment Programs Providing STI-Related Health Services With and Without Addiction Services Designed For: * p<0.05; # p<0.001

14. RESULTS: Treatment Program Characteristics 79% of Treatment Programs were not-for-profit; 6% for profit; 13% governmental 79% of Treatment Programs were not-for-profit; 6% for profit; 13% governmental Almost 80% of Treatment Programs had addiction services tailored to women or one minority population group Almost 80% of Treatment Programs had addiction services tailored to women or one minority population group Treatment Programs with addiction services tailored to women or one minority population group were more likely to provide: Treatment Programs with addiction services tailored to women or one minority population group were more likely to provide: –outpatient addiction services (86% versus 57%, p<0.001) –support services (92% versus 70%, p=0.01)

15. RESULTS: Infection-Related Health Services Non-medical services were provided more frequently than medical services Non-medical services were provided more frequently than medical services Treatment Programs with addiction services tailored to women or one minority population group were more likely to provide: Treatment Programs with addiction services tailored to women or one minority population group were more likely to provide: –HIV-related patient education (94% versus 85%, p=0.05) –HIV-related counseling (76% versus 60%, p=0.03) Treatment Programs with addiction services tailored to women were more likely to provide: Treatment Programs with addiction services tailored to women were more likely to provide: –HIV-related medical monitoring (53% versus 37%, p=0.03); odds ratio: 1.93 (95% CI: 1.07-3.49) –HCV-related risk assessment (81% versus 66%, p=0.01); odds ratio: 2.23 (95% CI: 1.18-4.20)

16. RESULTS: Infection-Related Health Services (cont’d) Of the 21 infection-related health services (7 services x 3 infections): Of the 21 infection-related health services (7 services x 3 infections): –16 of 21 were more available in treatment programs with addiction services designed for African Americans –9 of 21 were more available in treatment programs with addiction services designed for Latino Americans –5 of 21 were more available in treatment programs with addiction services designed for American Indians/Alaskan Natives –4 of 21 were more available in treatment programs with addiction services designed for Asian Americans

17. RESULTS: Barriers to Providing Infection-Related Health Services In Treatment Programs with addiction services designed for special populations: Funding was the most cited barrier; especially for medical services as compared to non-medical services Funding was the most cited barrier; especially for medical services as compared to non-medical services Health Insurance was the 2 nd most cited barrier: Health Insurance was the 2 nd most cited barrier: –for 19 of 21 infection services in programs designed for women –for all infection services in programs designed for African Americans –for 16 of 21 infection services in programs designed for Latino Americans –for 10 of 21 infection services in programs designed for American Indians/Native Alaskans –for 5 of 21 infection services in programs designed for Asians –for 6 of 21 infection services in programs designed for Hawaiians/Pacific Islanders

18. RESULTS: Barriers to Providing Infection-Related Health Services (cont’d) In Treatment Programs with addiction services designed for special populations: Patient Acceptance was the 3 rd most cited barrier: Patient Acceptance was the 3 rd most cited barrier: –for 11 of 21 infection services in programs designed for American Indians/Native Alaskans –for 16 of 21 infection services in programs designed for Asians –for 15 of 21 infection services in programs designed for Hawaiians/Pacific Islanders

19. LIMITATIONS Self-reporting of study population may be biased Self-reporting of study population may be biased Generalizability of results Generalizability of results No information about utilization, costs, efficiency, or effectiveness No information about utilization, costs, efficiency, or effectiveness

20. CONCLUSIONS Nearly 80% of treatment programs provide addiction services designed for at least one special population Nearly 80% of treatment programs provide addiction services designed for at least one special population Treatment programs offer an array of infection-related health services Treatment programs offer an array of infection-related health services Infection-related health services were more available in treatment programs with minority-tailored addiction services Infection-related health services were more available in treatment programs with minority-tailored addiction services Funding, patient health insurance, and patient acceptance were the most cited barriers Funding, patient health insurance, and patient acceptance were the most cited barriers

21. CONCLUSIONS Implications are: These health services serve as another mechanism explaining the infection-related benefits of substance abuse treatment These health services serve as another mechanism explaining the infection-related benefits of substance abuse treatment Despite barriers, treatment programs provide access to infection-related health services, more so in treatment programs with addiction services designed for women and minorities Despite barriers, treatment programs provide access to infection-related health services, more so in treatment programs with addiction services designed for women and minorities Removing these barriers may enhance the availability of infection-related health services especially important in treatment programs serving populations sustaining a greater burden of the consequences associated with these infections Removing these barriers may enhance the availability of infection-related health services especially important in treatment programs serving populations sustaining a greater burden of the consequences associated with these infections