Outpatient substance abuse treatment and HIV prevention: An update

Journal of Substance Abuse Treatment 30 (2006) 39 – 47

Outpatient substance abuse treatment and HIV prevention: An update Harold A. Pollack, (Ph.D.)a,4, Thomas D’Aunno, (Ph.D.)b, Barbara Lamar, (Ph.D.)c a

University of Chicago, Chicago, IL 60637, USA b INSEAD, 77305 Fontainebleau Cedex, France c Institute for Social Research, University of Michigan, Ann Arbor, MI, USA Received 3 November 2004; received in revised form 21 September 2005; accepted 27 September 2005

Abstract Testing and counseling, along with community outreach, have been identified as valuable in the prevention of human immunodeficiency virus (HIV) and other blood-borne diseases. This article assesses the extent to which outpatient substance abuse treatment (OSAT) programs provide such services. Longitudinal data for 1988–2000 were analyzed from the National Drug Abuse Treatment System Survey (NDATSS). Random-effects regression was used to examine factors associated with the provision of prevention services. HIV testing, which had became more common between 1990 and 1995, continued to proliferate between 1995 and 2000. The proportion of units that provide HIV testing and counseling increased from 66% to 86%. The proportion of units that provide HIV community outreach increased significantly before 1995 but then slightly decreased from 77% to 73% between 1995 and 2000. In conclusion, HIV testing and counseling widely proliferated in OSAT care. However, OSAT units remain less likely to offer HIV community outreach services. D 2006 Elsevier Inc. All rights reserved. Keywords: HIV testing and counseling; Outpatient substance abuse treatment; Outreach; Prevention

1. Introduction Human immunodeficiency virus (HIV) and other bloodborne agents remain as principal threats to the health of men and women who use illicit drugs. Approximately 300,000 injection drug users (IDUs) in the United States have been diagnosed with acquired immunodeficiency syndrome (AIDS) since 1980 (CDC, 2003a). The incidence of HIV/ AIDS has declined among drug users; however, in 2000 alone, more than 11,600 new cases of AIDS in the United States, 28% of all new United States cases reported, were associated with injection drug use (CDC, 2002). Several other important blood-borne diseases are also widespread among drug users, particularly among IDUs. Hepatitis C virus (HCV) may be the most prevalent and least controlled of these blood-borne agents. Hepatitis C

4 Corresponding author. E-mail addresses: [email protected] (H.A. Pollack)8 [email protected] (T. D’Aunno)8 [email protected] (B. Lamar). 0740-5472/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2005.09.002

virus acquired through previous drug use is the most common diagnosis leading to hepatic failure among patients requiring liver transplants. Many populations of IDUs who display a low prevalence of HIV display high HCV prevalence (Garfein et al., 1998). Pollack and Heimer (2004) reviewed the literature that explores HCV prevalence among IDUs in industrial democracies. Reported prevalence varied across countries but exceeded 65% in most studied populations. Only 4 of 40 studies examined indicated an HCV prevalence lower than 50%. In response to the continued incidence and prevalence of blood-borne diseases, several kinds of practices and programs have been shown to be both effective and cost– effective in preventing infectious diseases among drug users (Barnett, 1999; CDC, 1998; Choi & Coates, 1994; Coutinho, 1998; D’Aunno, Vaughn, & McElroy, 1999; D’Aunno & Pollack, 2002; Des Jarlais et al., 1995; Heimer, Kaplan, Khoshnood, Jariwala, & Cadman, 1993; Holtgrave, Qualls, & Graham, 1996; Holtgrave, Reiser, & Di Franciesco, 1997; Holtgrave, 1998; Holtgrave & Kelly, 1996; Institute of

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Medicine [IOM], 1995, 2000; Kahn, 1996; Kaplan & Pollack, 1998; Metzger & Navaline, 2003a; Pollack, 2001; Pollack, 2002a; Rahman, Fukui, & Asai, 1998; van Empelen et al., 2003; Zaric, Brandeau, & Barnett, 2000). One of the most important of these practices is HIV testing, which is recognized as a basic component of high-quality care to populations at risk of acquiring blood-borne infection (IOM, 2000). Identification of HIV infection makes possible the link to effective medical care and pharmacological treatment. From a prevention perspective, clinicians, policymakers, and researchers have paid heightened attention to prevention services provided to known HIV-infected persons. Recent guidelines for prevention services for HIV-positive individuals underscore the value of testing as an element of an effective HIV prevention strategy among drug-using populations (CDC, 2003b). Community outreach is a second key prevention practice whose effectiveness is well documented among drug users. These interventions include distribution of risk reduction information and referral to treatment services, condom and bleach distribution, and demonstration and rehearsal of risk reduction skills (Barnett, 1999; D’Aunno & Pollack, 2002; Holtgrave et al., 1996; IOM, 1995; Pollack & Heimer, 2004). Taken together, these practices constitute what has come to be known as a standard intervention whose effectiveness was examined in two large-scale multisite studies of HIV prevention (Needle, Coyle, Normand, Lambert, & Cesar, 1998). Community outreach has been shown to reduce HIV incidence among street drug users. Some of the strongest results come from the 29-site National AIDS Demonstration Research project and its successor project, the Cooperative Agreement for HIV/AIDS Community-Based Outreach/ Intervention Research Program. Summarizing these studies, Coyle, Needle, and Normand (1998) reported that participation in outreach interventions is associated with a significant reduction in the frequency and duration of injection drug use and with reduced prevalence of key risk behaviors such as needle sharing and reuse (Coyle et al., 1998; D’Aunno et al., 1999; Metzger & Navaline, 2003a, 2003b). Community outreach efforts are particularly important among IDUs because an estimated 50% – 85% of IDUs are not in treatment at any one time (Needle et al., 1998). HIV testing and counseling and community outreach are complementary prevention services; they are intended to reach two groups. On one hand, HIV testing and counseling can be provided when individuals are willing and able to frequent a site that provides testing, such as a substance abuse treatment unit or a public health office. In contrast, community outreach intends to bring prevention information and practices to a large group of IDUs who are not actively seeking treatment and/or who have varying motivations to reduce risky behaviors. For many reasons, clinicians and policymakers have focused special attention on the role of substance abuse treatment programs in HIV prevention (Metzger & Navaline, 2003a; Metzger, Navaline, & Woody, 1998).

The IOM’s No Time to Lose: Making the Most of HIV Prevention, which is its most recent assessment of HIV prevention, noted the special promise of outpatient substance abuse treatment (OSAT) units to address prevention (IOM, 2000; Pollack, 2002b). At the most basic level, substance abuse treatment reduces HIV incidence by reducing the rate of injection drug use and other HIV risk behaviors among current clients (Metzger & Navaline, 2003b). Methadone maintenance programs have received the most systematic research attention, although other modalities have also been shown to be effective in reducing HIV risk (Avins et al., 1997; Gottheil, Lundy, Weinstein, & Sterling, 1998; Reback, Larkins, & Shoptaw, 2004; Shoptaw, Frosch, Rawson, & Ling, 1997). Many studies have indicated reduced HIV incidence and prevalence among methadone clients, although this success may not be replicated in the prevention of HCV (Crofts et al., 1994; Crofts, Nigro, Oman, Stevenson, & Sherman, 1997; Metzger & Navaline, 2003a; Metzger et al., 1993; Metzger et al., 1998; Zaric et al., 2000). Outside the United States, studies such as the Amsterdam Cohort Study have reported comparable findings (Langendam, van Brussel, Coutinho, & van Ameijden, 2000). The impact of treatment-based interventions on sexual transmission risk appears smaller and more ambiguous in existing research (Somlai, Kellym, McAuliffe, Ksobiech, & Hackl, 2003; van Empelen et al., 2003). Many OSAT facilities have the capacity to refer HIVinfected clients to medical providers. Outpatient substance abuse treatment facilities also provide counseling and other services that may help clients maintain adherence to prescribed HIV therapies. HIV prevention programs within treatments are especially important given the reality of high relapse rates and nonadherence among substance abuse treatment clients. Although substance abuse treatment seeks to achieve complete cessation of drug use, data from many settings indicate that most clients do not achieve this aspiration. Many United States studies found that most methadone maintenance clients experience some level of future drug use (Ball & Ross, 1991). Data from other Organization for Economic Cooperation and Development countries also indicate frequent relapse among treatment clients (Farrell, 1995; Langendam et al., 2000). Although complete cessation of drug use is not typically achieved, many clients reduce their frequency of drug use and may eventually halt their drug use. Even if relapse eventually occurs, substance abuse treatment is associated with significant periods of halted or reduced drug use and with reduced HIV risk behaviors among those who continue active drug use. Moreover, substance abuse treatment may slow disease spread by including harm reduction elements, such as instruction about the hazards of syringe sharing and on the proper use of bleach, thereby reducing future risks (IOM, 1995). In-treatment IDUs are less likely than out-of-treatment IDUs to share needles and practice other HIV risk behaviors (Ball, Lange, Myers, & Friedman, 1988).

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For all the cited reasons, prevention practices and programs are especially important in OSAT. However, despite the availability of a large body of evidence to support the use of HIV prevention practices by OSAT units, many units do not offer or supply such prevention services. To address this issue, D’Aunno et al. (1999) examined the extent to which a representative national (United States) sample of several hundreds of OSAT units had adopted the use of HIV testing and counseling and outreach practices between 1988 and 1995. They found that the percentage of units engaged in outreach had increased significantly from 51% in 1988 to 75% in 1995. Similarly, the percentage of units offering HIV testing and counseling had increased significantly from 39% to 61% in the same years. These authors also identified characteristics of treatment units associated with the provision of HIV prevention practices. Outpatient substance abuse treatment units were more likely to offer prevention services to the extent that (1) a higher percentage of their clients were at higher risk of acquiring infection (e.g., injection users), (2) resources were available for prevention efforts, (3) external stakeholders supported prevention efforts (e.g., the Joint Commission on Accreditation of Health Care Organizations [JCAHO]), and (4) internal support existed for prevention (e.g., prevention efforts were consistent with the organizational mission). To our knowledge, there has been no recent national assessment of the extent to which OSAT units are continuing to engage in these critical HIV prevention efforts. Given large changes in the past decade in the nation’s OSAT system, including the rise of managed care, increase in for-profit OSAT units, and increased links to the criminal justice system, this article provides an update of the D’Aunno et al. (1999) analysis. In particular, it addresses two key questions: First, bTo what extent are the nation’s OSAT units engaged in HIV testing and counseling and outreach (and what changes, if any, have occurred in the past decade)?Q Second, bWhat factors are promoting or inhibiting the use of these practices?Q Following prior work (D’Aunno et al., 1999), we will explore these factors using an analytical model rooted in the organizational opportunities, capacities, and constraints facing OSAT units. Based on empirical results from the study of D’Aunno, Vaughn, et al. (1999), we expect that this analytical model will identify factors that promote or inhibit the adoption of both HIV testing and outreach practices. As noted, these two HIV prevention practices mainly differ in their focus on individuals with differing motivations for behavioral change. From the perspective of organizations and their managers, such differences among potential service recipients are not likely to be as important as the overall costs and benefits of providing the services (e.g., staff time, recognition among funding agencies and other social service organizations). The two services appear to be relatively similar on these dimensions. Outpatient substance abuse treatment units have limited resources and face multiple tasks and demands. Thus, units must choose to meet those demands that seem most

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pressing. We hypothesize that OSAT units that treat a large proportion of clients at risk of acquiring HIV infection will be more likely to adopt or maintain HIV prevention practices and programs. For these units, prevention becomes a necessary core service rather than an ancillary one. We operationalize this hypothesis by including the proportion of clients who are IDUs or who belong to minority race/ethnic groups (African American, Hispanic) that experience disproportionate rates of HIV infection. The need for an organizational innovation, such as HIV prevention services, must also be matched by the resources to support it. We therefore hypothesize that units with greater financial resources or with higher client:staff ratios will offer a broader range of pertinent services, including HIV prevention services, to OSAT clients (D’Aunno et al., 1999). Outpatient substance abuse treatment units whose staff have lower caseloads have more time to spend on HIV testing and counseling as well as outreach efforts. Furthermore, OSAT units with more revenues could spend funds to hire specialist HIV prevention staff. At the same time, OSAT units may have reasons to add or maintain HIV prevention services that go beyond basic client needs and available resources. Organizational norms and values can also influence service provision. Even organizations with a need for HIV prevention and resources to engage in prevention programs may believe that such efforts do not fall within the domain of their core mission. For example, hospitals traditionally focus on inpatient hightechnology services and may not view outreach programs as part of their core mission (D’Aunno et al., 1999). We hypothesize that OSAT units based in hospitals are more likely than others to offer HIV testing because this service fits their traditional medical mission. We hypothesize that hospitals will be less likely to provide outreach services because such services are not typically included in their domain. This hypothesis marks an exception to our general argument that the provision of both HIV testing and outreach is affected in similar ways by the factors in the proposed analytical approach. The reason for this exception is that hospitals have a particular identity rooted in the medical model of health care that minimizes their role in any type of outreach activity and, instead, emphasizes their role in more complex diagnostic services such as HIV testing. Furthermore, we expect that publicly owned OSAT units (compared with privately owned units) are more likely to value HIV prevention programs because such efforts are in keeping with their mission and norms about community service. Prior research shows that they are more likely to engage in outreach efforts (D’Aunno et al., 1999). Finally, delivery of HIV prevention services also may reflect the influence and constraints that external stakeholders such as local health and social service agencies as well as licensing and accreditation bodies impose. Some accrediting bodies, such as the JCAHO, encourage the provision of prevention services. Furthermore, local agencies may place subtle or overt pressure on OSAT units to

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prevent HIV among drug users. We therefore hypothesize that accreditation is associated with the provision of prevention services. The role of OSAT leaders in interacting with stakeholders is also important. Outpatient substance abuse treatment units run by directors who receive information from multiple external sources and who are externally oriented to the community and profession are more likely to be aware of both best practices in HIV prevention and stakeholders’ emphasis on using such practices. We hypothesize that units whose directors display this external orientation are more likely to provide HIV prevention services than are units whose directors report having less information about and interest in external affairs. In summary, we expect that OSAT units will be more likely to adopt or maintain HIV prevention practices when they see a compelling need to do so from their clients, when they have resources available to commit to such efforts, when their values and norms are consistent with HIV prevention practices and programs, and when external stakeholders encourage them to engage in these efforts.

2. Materials and methods Data for this study were drawn from the 1988–2000 National Drug Abuse Treatment System Survey (NDATSS), which is a longitudinal study that examines the organizational structure, operating characteristics, and treatment practices of the nation’s OSAT programs. Funded by the National Institute of Drug Abuse and conducted by the University of Michigan’s Institute for Social Research (ISR) and the University of Chicago’s National Opinion Research Center, the NDATSS includes four waves: 1988, 1990, 1995, and 1999– 2000. A facility must devote at least half of its services to the treatment of substance abuse disorders to qualify for the NDATSS. Moreover, most drug-related services must have been provided on an outpatient basis. The NDATSS sampling method is described in detail elsewhere. Briefly, the NDATSS uses a mixed-panel design that combines elements from panel and cross-sectional designs. Data are collected from the same national sample of outpatient drug abuse treatment units that have been sampled and screened as part of prior waves of the study. These panel units are combined with a new group of randomly selected OSAT units to ensure that the sample remains nationally representative at each wave. The new units are selected for participation from a sampling frame of the most complete list of the nation’s OSAT units (the National Frame for Substance Abuse Treatment Programs [NFSATP]), as compiled by the ISR (Adams & Heeringa, 2001; Heeringa, 1996). In 1988, 575 treatment units agreed to participate in the study (an 86% response rate). Given the high probability that the population of OSAT units did not change between 1988

and 1990, the participating units were recontacted in 1990. Of these units, 481 participated, for an 88% response rate. In 1995, units from the 1990 study were recontacted and a systematic random sample from the 1994 –1995 NFSATP was added. After screening and nonresponse, 618 organizations (including 387 panel units) completed the 1995 interviews, for a combined response rate of 86%. The 1999– 2000 NDATSS combines a panel component composed of 489 units, with an additional sample of 256 units drawn from the 1998 NFSATP. In total, 745 organizations completed interviews, for a response rate of 89%; of these, 387 were panel units that have participated in all four study waves. Sample attrition analyses have found no evidence of bias among cases that dropped out of the study between the waves of the NDATSS (D’Aunno, Folz-Murphy, & Lin, 1999; Vaughn, 1993). For illustration, analyses show that the percentage of units involved in managed care was virtually identical among the panel and new sample units in 1995 (Lemak, 1998). In each NDATSS wave, the administrative director and clinical supervisor of each OSAT unit were asked to complete a phone interview. Directors provided information concerning ownership, environment, finances, organizational structure, and managed care arrangements. Clinical supervisors provided information regarding staff composition, client characteristics, treatment practices, and available ancillary services. Several steps were taken before, during, and after data collection to ensure that the data have high levels of reliability and validity. For example, study staff conducted internal consistency checks of key numbers (e.g., numbers of clients) and, if necessary, called respondents back to clarify responses and address problems. Results were also compared with other surveys to further confirm validity. These checks revealed very high levels of consistency with the NDATSS data. For example, investigators have examined the validity of the data obtained from the NDATSS interviews by comparing those data to those of the Drug Services Research Study (DSRS), a national client-level investigation of drug treatment organizations. In this comparison, data on treatment duration from 323 methadone treatment units in the 1990 NDATSS closely matched findings obtained from discharge abstracts from 520 outpatient methadone units in the 1990 DSRS (Batten et al., 1992). In short, the study staff used telephone survey procedures that extensive research indicates will produce highly reliable and valid data (Groves et al., 1988). 2.1. Variables 2.1.1. Dependent variables In each survey wave, we measured the provision of two kinds of HIV prevention services. Clinical supervisors were asked whether their OSAT unit provided HIV testing (yes or no). Unit directors were asked if their OSAT unit conducted any outreach effort to prevent HIV (yes or no).

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Table 1 Descriptive statistics 1988 Dependent variables HIV outreach HIV testing Independent variables [M (SD for continuous variables)] No. of FTE treatment staff Ratio of OSAT clients to staff Total revenue Ways that a director stays current Sum of licenses Sum of referral sources Unit is in hospital Unit is publicly owned Percentage of African American clients Percentage of Hispanic/Latino clients Percentage of drug-injecting clients Urbanicity Years current director is in position No. of OSAT clients

0.55 0.45

12.37 (11.80) 66.26 (67.74) $474 ($1,294) 22.07 (3.48) 2.04 (1.16) 5.23 (1.04) 0.23 0.29 19.37 (21.47) 11.06 (17.87) 27.93 (32.60) 7.63 (2.47) 5.75 (5.12) 668.95 (852.80)

1990

1995

0.68 0.46

14.64 75.33 $584 17.66 2.03 5.13 0.24 0.29 20.35 9.59 26.98 7.79 5.57 615.81

0.77 0.66

(16.50) (123.50) ($929) (3.99) (1.21) (1.18)

(22.92) (17.09) (32.78) (2.54) (4.86) (785.02)

12.86 (14.50) 71.59 (87.32) $573 ($926) 21.68 (3.57) 1.83 (1.09) 4.82 (1.49) 0.18 0.24 23.06 (25.79) 11.52 (18.87) 20.57 (29.21) 7.92 (2.51) 6.39 (5.74) 572.10 (754.12)

2000 0.73 0.86

12.86 77.81 $623 21.00 2.00 4.49 0.13 0.20 24.82 13.48 21.34 8.01 6.40 615.55

(15.00) (102.04) ($957) (3.72) (1.19) (1.44)

(27.12) (19.94) (28.17) (2.48) (5.93) (1,115.44)

Source: 1988–2000 NDATSS data.

2.1.2. Independent variables We included diverse independent variables to address different hypotheses and important confounders.

positive response to this question was coded as 1; other responses were coded as 0. 2.6. Directors’ external activity and orientation

2.2. Client risk profile Clinical supervisors reported the percentage of clients in the last fiscal year who were Black, Hispanic, and intravenous drug users. Each of these categories is associated with increased HIV prevalence. 2.3. Resources Clinical supervisors reported the total number of OSAT clients and the number of full-time equivalents (FTEs) employed by their treatment unit in the last fiscal year. The number of OSAT clients was divided by the number of FTEs to create a client:staff ratio. Directors reported their total revenue for the most recent complete fiscal year by source (e.g., Medicaid and private insurance). Total revenue is expressed in millions of dollars (see Table 1).

Unit directors were asked seven questions about the extent to which they participate in activities to update their knowledge of current developments in the field of substance abuse. These activities include reading professional publications, attending conferences, participating in seminars and workshops, joining associations, participating in advisory boards and commissions, conducting market research, and engaging in informal conversations with colleagues outside their organization. Responses to each question ranged from 1 (no extent) to 5 (very great extent). These responses were summed, creating a variable with scores ranging from 7 to 35. 2.7. Connections to local service agencies

Unit directors were asked if their treatment unit was private nonprofit, private for profit, or publicly owned. Responses were recoded as either public (1) or private (0).

Clinical supervisors reported if their unit received client referrals from several possible sources, including courts, parole, and probation services; mental health agencies; hospitals and other health care providers; vocational rehabilitation services; and employee assistance programs. Responses were summed, creating a connections-to-localservices variable that ranged from 0 to 6.

2.5. Parent organization

2.8. Licensing and accreditation

Unit directors were asked if their unit was owned by, operated by, or had any affiliation with another organization; if unit directors replied yes to any of these questions, they were asked if the organization was a hospital. A

Unit directors reported if their unit currently held any of six licenses and accreditations (JCAHO, Food and Drug Administration, Drug Enforcement Administration, state agency, local agency, or some other). These responses were

2.4. Unit ownership

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summed, creating a license-and-accreditation-affiliation variable ranging from 0 to 6. 2.9. Time trends We created dummy variables to represent data from the 1988, 1990, and 1995 surveys, with the 1999/2000 survey used as the referent category. These time variables were used to model change in the dependent variables over time.

but not in others. By allowing the possibility of individual heterogeneity, random-effects models are more robust to possible nonresponse bias than are simple ordinary least squares specifications. We chose not to restrict our sample to units that participated in all survey waves because such sample restrictions appear to foster bias (Little & Rubin, 2002). Because the dependent variables are binomial, we used a generalized estimating equation logistic model.

2.10. Control variables 3. Results We controlled for the effects of three variables that could influence units’ adoption of HIV prevention practices. We controlled for size of the treatment unit as measured by the total number of outpatient substance abuse clients served in the past year, as reported by clinical supervisors; units with more clients might be less able to conduct outreach or HIV testing. We also controlled for the location of treatment units in urban versus rural areas. Location could affect their use of HIV prevention practices. Large urban areas include many service providers of various types that can play a role in HIV prevention. In contrast, rural treatment units are likely to face the pressures previously discussed to reduce HIV infection among intravenous drug users while having fewer available partners to share or perform HIV prevention work with. Urban versus rural location was measured using the Beale Urbanicity Code, which ranges from 0 (metropolitan centers with a population of 1 million or greater) to 9 (rural areas with fewer than 20,000 residents not adjacent to a metropolitan center). Finally, we controlled for the effects of unit director tenure (number of years in this position); more experienced directors might be less open to change in practices or might be better able to accept such changes. 2.11. Statistical analyses Because a large number of treatment units participated in the study in all the available waves, the data must be analyzed as panel data. In panel data, multiple observations from the same unit are obtained over time; these observations are likely to be correlated (i.e., the dependent variables measured from the same unit over time are likely to be similar). Standard linear and logistic regression models, which assume independence among observations, must therefore be augmented. Thus, we analyzed the data using random-effects models that account for correlation among repeated measures of the same units over time (Diggle, Liang, & Zeger, 1994). For each dependent variable, a random-effects model uses all data from the four waves (2,419 total observations) and accounts for correlations in the error term that flow from repeated observations at the same treatment unit. All available data were used in each survey wave, including data from units that participated in some years

Table 1 shows descriptive statistics. Our independent variables appeared quite stable between the 1995 and 1999/ 2000 NDATSS waves. HIV testing, which had became more common between 1990 and 1995, continued to proliferate in the subsequent waves. Between 1995 and 2000, the proportion of units that provide HIV testing increased from 66% to 86% ( p b .001). Much of the increase reflected the continued diffusion of HIV testing and counseling to units not traditionally associated with IDUs. We saw no similar increase in HIV outreach efforts. Indeed, the proportion of OSAT units conducting outreach slightly declined (from 77% to 73%) between the two NDATSS waves. Table 2 shows our multivariate regression results. 3.1. HIV testing Controlling for potential confounders, we saw a strong time trend in the provision of testing services. Differences between 1995 and 2000 appeared no less pronounced than those between 1995 and earlier waves. Aside from the strong time trend, provision of HIV testing was associated with several characteristics of OSAT units and their client populations. Client risk profile was associated with increased testing. Units that serve a high proportion of IDUs were significantly more likely to provide testing. Units that serve a high proportion of African American and Hispanic clients were also more likely to provide testing, although these coefficients were only marginally significant ( p b .10) for both variables. This pattern may also reflect client risks given the relatively high incidence of HIV among non-Whites (CDC, 2003a). Units with fewer clients per staff were significantly more likely to provide testing services. Units with a higher number of licenses and accreditations were also more likely to provide testing services. In follow-up analyses, we found that JCAHO accreditation was a particularly strong correlate of testing. Units with more links with local referral sources were also more likely to provide testing. Public ownership was associated with a significantly increased probability of HIV testing.

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Table 2 Generalized estimating equation analysis of HIV testing and outreach

1988 1990 1995 2000 Ratio of OSAT clients to staff Total revenue ($) Ways that a director stays current Sum of licenses Sum of referral sources Unit is in hospital Unit is publicly owned Percentage of African American clients Percentage of Hispanic/Latino clients Percentage of drug-injecting clients Urbanicity No. of years director is in current position No. of OSAT clients

HIV testing [h coefficient (95% confidence interval)]

HIV outreach [h coefficient (95% confidence interval)]

2.529*** ( 2.88 to 2.17) 2.28*** ( 2.64 to 1.92) 1.27*** ( 1.58 to 0.97) Referent 0.0021** ( 0.0036 to 0.0007) 0.001 ( 0.0001 to 0.0002) 0.018 ( 0.0120 to 0.047) 0.338*** (0.22 to 0.46) 0.110* (0.010 to 0.210) 0.05 (0.231 to 0.332) 0.455*** (0.19 to 0.72) 0.0046 ( 0.0007 to 0.0098) 0.0086 ( 0.0005 to 0.0131) 0.009*** (0.0036 to 0.135) 0.015 ( 0.0376 to 0.0676) 0.0019 ( 0.0188 to 0.0226) 0.0001 ( 0.0002 to 0.0004)

1.09*** 0.053 0.142 Referent 0.012* 0.0001 0.083*** 0.058 0.157*** 0.24 0.133 0.0024 0.0045 0.0039 0.056* 0.0076 0.0003*

( 1.37 to 0.80) ( 0.36 to 0.26) ( 0.13 to 0.41) ( 0.0023 to 0.0001) ( 0.0002 to 0.0004) (0.054 to 0.112) ( 0.06 to 0.18) (0.07 to 0.24) ( 0.50 to 0.027) ( 0.14 to 0.40) ( 0.0024 to 0.0072) ( 0.0015 to 0.011) ( 0.0008 to 0.0087) ( 0.11 to 0.006) ( 0.013 to 0.028) (0.0001 to 0.0005)

Source: 1988–2000 NDATSS data. 4 p b .05. 44 p b .01. 444 p b .001.

3.2. HIV outreach services We found somewhat different results in our analysis of HIV outreach services. We found no evidence of increased provision over time. Indeed, we could not reject the hypothesis that outreach had remained unchanged in the 1995 and 2000 NDATSS waves. As in the case of HIV testing, units with fewer clients per staff were more likely to implement outreach services. Linkages to the community, as reflected by multiple referral sources, were also correlated with increased provision of outreach services. Larger units and those headed by directors who report many ways of staying current in the field were more likely to provide outreach services. In contrast to the results for HIV testing, we found no statistically significant relationship between the proportion of IDUs whom a unit serves and its use of outreach services. Surprisingly, measures of accreditation and urbanicity were not associated with provision of outreach services. We also examined the possible effects of geographic region and found no significant relationship for either HIV testing or outreach. Finally, we explored the possible effects of an alternative measure of units’ financial resources, profit margin (measured as operating revenue minus operating costs), but found no effect.

4. Discussion This article examined the provision of HIV testing and outreach services among OSAT units. It has one principal limitation. Owing to data limitations, we examined units’ adoption of HIV testing and outreach services. We could not

examine the percentage of clients at each unit who received these services. It is important to know more about the percentage of clients who actually receive services because, in the worst case, there may be many units offering services but few clients receiving them. The use of binary measures of service adoption also reduced the study’s statistical power. Furthermore, because we have unit-level, rather than clientlevel, data, we cannot explore client characteristics associated with service receipt or the impact of such services on treatment outcomes. We also cannot examine the quality of outreach services provided by OSAT units. Despite these limitations, we find several patterns worthy of note. Our most encouraging finding is that the proportion of OSAT units that provide testing increased by 20% between 1995 and 2000. By 2000, almost 90% of OSAT units reported that they provide at least some degree of HIV testing. The proportion of units offering HIV testing is even higher among those that serve a high proportion of IDUs. HIV testing is a basic component of high-quality care. The identification of HIV infection makes possible the link to medical care. Over the past decade, clinicians, policymakers, and prevention researchers have paid heightened attention to prevention services provided to known HIVinfected persons. Recent guidelines for prevention services for HIV-positive individuals underscore the value of HIV testing as a prevention strategy among drug-using populations (CDC, 2003b). Our findings suggest that OSAT units are key participants in this prevention effort. Units with greater financial resources and those with JCAHO accreditation were more likely than others to provide testing services. Both of these measures are correlated with other dimensions of OSAT quality such as

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methadone dose level (D’Aunno & Pollack, 2002). As provision of HIV testing becomes identified as a basic component of best-practice OSAT (IOM, 2000), units that regard themselves to be of high quality may be especially likely to incorporate this service. Public ownership was also associated with the provision of HIV testing. Publicly owned units are often linked with state and local health departments that play an active role in HIV testing and counseling. For similar reasons, publicly owned units may regard public health as an important organizational goal. This pattern is consistent with prior research highlighting the sharp contrast in roles between public and private providers, with public providers assuming a greatly increased public health and safety net role, serving populations at greatest risk of acquiring HIV infection (Wheeler & Nahra, 2000). Results regarding HIV community outreach services were less encouraging. Given the documented value of such services in reducing HIV incidence among in-treatment and out-of-treatment drug users, we were disappointed to find that the proportion of OSAT units providing community outreach actually declined slightly between 1995 and 2000. More than one quarter of OSAT units reported that they provide no outreach services at all. It is possible that OSAT units regard outreach services as peripheral to a core mission rooted in the provision of treatment services. Outpatient substance abuse treatment directors, clients, and staff may also be ambivalent about the harm reduction dimension of many outreach services. Previous research suggest that OSAT units headed by directors expressing abstinence-oriented perspectives provide more constrained services, including lower methadone doses, to IDUs (D’Aunno & Pollack, 2002; D’Aunno & Vaughn, 1992). We hope to explore these issues in future research with more detailed data. Whatever the explanation, the limited outreach efforts of OSAT units reflect a missed opportunity for public health. The IOM has identified the treatment settings as central to improved HIV prevention efforts (IOM, 2000; Pollack, 2002b). Similar to parts of the criminal justice system, OSAT facilities are positioned to identify and serve infected persons who might otherwise have limited contact with traditional health care services (Hammett, Gaiter, & Crawford, 1998). As Metzger et al. (1998) observed, OSAT units are one of the few organized social institutions with access to drug users at risk of acquiring HIV infection. We respect the desire of many providers to promote abstinence or greatly reduced substance use as a primary goal of OSAT interventions. Outreach services are nonetheless essential, given the reality that most OSAT clients will persist or relapse, for some period, in their substance use. Demonstration and rehearsal of risk reduction skills, referrals to treatment services, and other outreach services are proven ways that OSAT facilities could contribute to reduced mortality and morbidity from HIV and other diseases.

Acknowledgments Preparation of the manuscript was facilitated by Grant 5R01-DA-3272-18 from the National Institute on Drug Abuse, Rockville, MD, and by a seed grant from the Chicago Center of Excellence in Health Promotion Economics, Chicago, IL.

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