In the current study, we found that although a majority of substance abuse treatment programs within the NIDA CTN offered health services for HIV/AIDS, HCV, and STI, a substantial percentage did not, particularly for medical services, representing a missed opportunity to positively affect these infectious disease epidemics. These findings are particularly striking because substance abuse program administrators were asked about services provided either onsite or by contractual agreement with another provider. Therefore, the percentage of programs that offered only onsite services was even lower. In view of the fact that treatment programs within the NIDA CTN generally have closer linkages with university settings than non-NIDA CTN treatment programs, NIDA CTN treatment programs might be expected to offer more evidence-based services than non-NIDA CTN treatment programs. This means that services offered by non-NIDA CTN treatment programs, which comprise the vast majority of treatment programs in the United States, might be expected to be lower still.
More importantly, this report categorized and confirmed what had previously been assumed to be the barriers to offering specific medical and nonmedical health services for these infections in substance abuse treatment programs. These findings have important implications for the estimated 19.1 million current illicit drug users in the United States26
and represent missed opportunities to diagnose, treat, and prevent further transmission of these infections.
Despite the major public health importance of HIV/AIDS, HCV, and STI epidemics among substance abusers, few studies have comprehensively evaluated the range of health services offered for these infections in substance abuse treatment programs in the United States. Although estimates vary widely, these studies showed that a disappointingly high proportion of substance abuse treatment programs did not offer any testing for HIV (14.0% to 69.3%),20–22
HCV (22.7% to 76.7%),20,22,24
or STI (57.8% to 78.4%).20,22
In addition to confirming the suboptimal availability of HIV/AIDS, HCV, and STI services in substance abuse treatment programs, our study also provides more definitive insight into the barriers to providing these health services.
Program administrators and clinicians identified funding and patient and client health insurance benefits as the biggest barriers to providing medical and nonmedical services for HIV/AIDS, HCV, and STI in substance abuse treatment programs. Given the high prevalence of these infections among substance abusers, combined with the fact that these individuals are largely responsible for sustaining transmission of these infections in the United States, it would be prudent to improve integrated delivery of these health services. Possible solutions include reallocating existing substance abuse treatment program funds, increasing state and federal funding, evaluating more cost-effective strategies for providing care, or a combination of these approaches.
Another published report from this study, which included information from a survey of state health and substance abuse department administrators, showed that there was a substantial mismatch between availability of funding from states and knowledge of these funding sources at the program administrator level,27
indicating that funding was often more available than was recognized. This could be remedied simply through better communication between state agencies and the treatment programs that they oversee and fund. The optimal solution to this public health problem is uncertain at this time, but it is clear that health services research studies to evaluate the feasibility, effectiveness, and cost-effectiveness of these strategies in clinical practice are a logical next step.
In addition to funding and patient and client health insurance benefits, we also identified patient and client acceptance and staff training as being important barriers to delivering health services for these infections. Therefore, it is important that program administrators, clinicians, and patients be educated on screening, diagnosis, treatment, and risk-reduction measures so that transmission of these infections can be reduced. Even if funding were available, there are still other barriers that need to be overcome.
The strengths of the current study include the large number of substance abuse treatment programs surveyed, the geographic diversity of these programs, inclusion of both program administrators and clinicians, the high response rates from treatment program administrators (84.3%) and clinicians (78.0%), and the collection of comprehensive information about health services offered for HIV/AIDS, HCV, and STI. In addition, our study is unique because we are unaware of any previous studies that have comprehensively evaluated barriers to providing care for HIV/AIDS, HCV, and STI in substance abuse treatment programs across the United States.
There are several limitations of this study to consider when interpreting our findings. First, we surveyed only substance abuse treatment programs within the NIDA CTN, and the services provided by these programs and barriers identified may differ from those associated with substance abuse treatment programs that do not participate in this network. However, this is unlikely because the distribution of the size and structure of the 269 programs that returned completed questionnaires were, to a large extent, similar to the distribution of the 13,454 programs in the National Survey of Substance Abuse Treatment Services study.22,28
As noted above, the barriers to offering these services in non-CTN settings are likely to be even more pronounced due to presumably less connection with university centers and the latest evidence-based practices.
Second, we evaluated program administrator and clinician barriers to providing HIV/AIDS, HCV, and STI services but did not survey the substance abusers that would actually use these services. It is possible that the perspectives of the patients differ from that of program administrators and clinicians.
Third, given that HIV treatment is life-long and HCV treatment is prolonged, there may be significant incongruity between length of stay in substance abuse treatment and ability to treat these infections. Our study did not address these and other logistical issues. However, from the outset this study was intended to be exploratory and hypothesis generating, which is what this limitation highlights. Despite these limitations, our findings shed light on the challenges that substance abuse treatment programs face regarding delivery of infection-related services in the context of limited funding.
We found that there was less than robust availability of comprehensive health services for HIV/AIDS, HCV, and STI in substance abuse treatment programs within the NIDA CTN, and by extension, the entire United States. We have categorized and confirmed what had previously been assumed to be the specific barriers to providing these services. Because substance abuse treatment programs are an important point of contact to provide risk-reduction counseling, testing, and treatment for these infections, these identified shortcomings provide opportunities for public health intervention.