SUDs and HIV

Goal 4(ii): Patients with SUDs and HIV

Management of patients with SUDs and comorbid HIV is a target of collaboration between the SUD and the HIV/Hepatitis QUERIs.  Building on the FY06 work of the joint SUD-HIV/Hepatitis Task Group (Dookeran et al., unpublished work) finding that only 19.6% of a national sample of patients with histories of SUD had received HIV education and testing, and then only if specifically requested, Dr. Hagedorn, Dr. Henry (HIV/HEP C QUERI IRC), and Dr. Anaya (HIV/HEP C QUERI Investigator) have established a working group to begin developing a line of implementation research to promote rapid HIV testing in SUD clinics. Planning is in the initial stages, but will include a developmental formative evaluation survey of VA SUD clinics that will document current practice regarding HIV testing in SUD clinics, identify potential barriers and facilitators to rapid HIV testing in SUD clinics, and assess the perceived utility of implementation of rapid HIV testing in SUD clinics. While the survey project is underway, Dr. Hagedorn will also begin working with the Liver Health Initiative stake holder group at the Minneapolis VAMC to develop a plan for integrating rapid HIV testing into the already established Healthy Liver Group, changing its focus from hepatitis infections specifically to infectious disease more broadly. Experience with implementation in Minneapolis will serve as a model and inform future implementation efforts in additional clinics.

Dr. Hagedorn is also a co-investigator on the MH and HIV QUERI HI-TIDES project to implement collaborative care for depression in HIV clinics. Dr. Hagedorn was instrumental in the development of a script for alcohol and drug use screening and brief interventions for alcohol misuse and abuse that is used by the nurse care manager.

Buprenorphine can be an effective treatment for opioid addiction among HIV+ patients. (Fiellin, 2004; McCance-Katz, 2005). However, a recent report concluded that barriers to the integration of buprenorphine in HIV primary care include "lack of expertise, bias, intolerance, lack of patient-physician trust, and lack of resources" (p. 8, Forum for Collaborative HIV Research Workshop, 2004).  Similar barriers may exist to providing effective brief interventions for alcohol misuse in HIV clinics or HIV primary care.  To explore these issues, in FY06, the SUD and HIV/Hepatitis QUERIs formed a Task Group co-led by Dr. Gifford, Co-Research Coordinator of the HIV/Hepatitis QUERI, and by Dr. Gordon of the SUD QUERI Buprenorphine Task Group.  Dr. Kosten met with the HIV/Hepatitis QUERI Executive Committee in September 2006 to prioritize future implementation collaborations including: (i) Rapid HIV testing in SUD clinics (following resolution of VA policy issues under review by the PHSHG), (ii) Access to buprenorphine in selected HIV clinics with high opioid use, (iii) Appropriate pharmacotherapy for alcohol dependence in HIV clinics, and (iv) Continued collaboration on smoking cessation for HIV/AIDS patients as part of Dr. Sherman's implementation project in VISNs 21 and 22. In 2007, our collaboration has addressed several of these priorities: (i) Policy issues on this HIV testing, including counseling, on the testing are still resolving. We have identified the station-level prevalence of patients with comorbid HIV and diagnosed opioid dependence from the HIV registry in order to target those needing HIV testing, and we have provided input on items to assess screening and counseling for HIV in an ongoing SUD providers' survey.  (ii) We are identifying VHA HIV providers who are willing to receive the required training and DEA waiver to allow them to prescribe buprenorphine and arranging consultation for them.  We also are expanding our joint efforts to implement the use of buprenorphine with opioid-dependent patients, with or at risk for HIV, in stations that do not have methadone maintenance.  (iii) In Houston and other VA sites with large HIV clinics, we have begun systematic inservice training at the HIV clinics on how to use available alcoholism relapse prevention agents, such as naltrexone and acamprosate.  (iv) Smoking cessation pilot studies have begun in several HIV clinics, including Houston, where a proposal for tele-monitoring for relapse prevention has been adapted from a successful NCI and NIDA-funded program for smoking cessation in non-VA HIV patients.

• Through conference calls and meetings, a joint Work Group of the SUD and HIV QUERIs collaborated on a survey of 31 of 34 active VA methadone clinic leaders to identify current practices in HIV testing, counseling and follow-up. Although all participating clinics provided HIV education and testing to their patients, they generally are provided only if requested, rather than routinely. According to the clinic leaders, the most common barriers to completing HIV testing are patients' fears about the results, patients' desire not to know their HIV status, and patients' perceptions that they are not at risk.
• Under the mentorship of Dr. Gifford (HIV/Hepatitis QUERI Research Coordinator), Dr. Dookeran found that only 19.6% of a national sample patients with histories of SUD had evidence of HIV testing.
• Dr. Hagedorn, Dr. Henry (HIV/Hepatitis QUERI IRC), and Dr. Anaya (HIV/Hepatitis QUERI Investigator) have established a working group to begin developing a line of implementation research to increase HIV testing in SUD clinics through promotion of rapid HIV testing.
• Dr. Hagedorn is a co-investigator on the MH and HIV QUERI HI-TIDES project to implement collaborative care for depression in HIV clinics. Dr. Hagedorn was instrumental in the development of a script for substance use screening and brief interventions for alcohol misuse that is used by nurse care managers.
• Dr. Kosten met with the HIV QUERI Executive Committee to prioritize future implementation collaborations, including access to buprenorphine in HIV clinics with high opioid use, promoting appropriate pharmacotherapy for alcohol dependence in HIV clinics and continued collaboration on smoking cessation for HIV/AIDS patients as part of Dr. Sherman's implementation project in VISN's 21 and 22.

Progress and Accomplishments

• Impacts, Contributions and Products
• Planned Projects