A comparison of HCV antibody testing in drug-free and methadone maintenance treatment programs in the United States

A comparison of HCV antibody testing in drug-free and methadone maintenance treatment programs in the United States

Drug and Alcohol Dependence 73 (2004) 227–236 A comparison of HCV antibody testing in drug-free and methadone maintenance treatment programs in the U...

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Drug and Alcohol Dependence 73 (2004) 227–236

A comparison of HCV antibody testing in drug-free and methadone maintenance treatment programs in the United States Shiela M. Strauss a,∗ , Janetta M. Astone a , Don Des Jarlais b , Holly Hagan a b

a National Development and Research Institutes, Inc., 71 West 23rd Street, 8th Floor, New York, NY 10010, USA Baron Edmond de Rothschild Foundation Chemical Dependency Institute, Beth Israel Medical Center, New York, NY 10003, USA

Received 22 March 2003; received in revised form 13 August 2003; accepted 13 August 2003

Abstract Drug treatment programs are uniquely situated to screen patients for antibodies for hepatitis C virus (HCV), an infectious disease that has reached epidemic proportions among drug users. This paper compares the accessibility and patients’ use of opportunities for HCV antibody testing in a large sample of methadone and drug-free treatment programs (N = 256) in the US, and reports programs’ recent changes and future plans concerning it. Results indicate that almost all methadone and about two-thirds of drug-free programs in the sample provided HCV antibody screening to at least some patients in 2001. While about two-thirds of the methadone and close to one-third of the drug-free programs offered this service to all patients, these programs report that only about 3/5 of their patients actually provided specimens for testing for HCV antibodies. Some drug treatment programs were planning to increase the availability and accessibility of HCV antibody screening, but others were planning to cut back on these services, primarily due to limited resources. These results can inform policymakers who advocate for increased HCV antibody screening in drug treatment programs about the current level and future plans for implementing these services, illuminating where resources and motivational efforts need to be targeted. © 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Hepatitis C; Screening; Drug treatment programs; Methadone maintenance; Health services

1. Introduction In recent years, hepatitis C virus (HCV) has reached epidemic proportions, with an estimated 4 million people infected in the United States (Alter et al., 1999). Given the ease with which HCV is transmitted via multi-person use of contaminated injection equipment, many of those infected with HCV include past and current drug injectors (Alter and Moyer, 1998; Hagan et al., 2001; Williams, 1999). Depending on the geographic location and data collection setting (e.g., in-treatment or out-of-treatment), infection rates among injection drug users (IDUs) have typically been found to range from 60 to 90% (Alter, 1997; Lorvick et al., 2001; McCarthy and Flynn, 2001). In addition, about two thirds (68%) of newly acquired cases of hepatitis C are related to injection drug use (Alter, 2002), with incidence rates among IDUs generally ranging from 10 to 20% per year (Garfein ∗ Corresponding author. Tel.: +1-212-845-4409; fax: +1-917-438-0894. E-mail address: [email protected] (S.M. Strauss).

et al., 1998; Hagan et al., 1999, 2001; Hahn et al., 2001; Thorpe et al., 2002). Non-injection drug users, especially those who smoke crack cocaine or use cocaine intranasally, are also at increased risk for HCV infection (Rosenberg et al., 2001; Rosenblum et al., 2001; Tortu et al., 2001). Alarmingly, chronic hepatitis C infection develops in 60–85% of people who experience the acute phase of the virus (National Institutes of Health, 2002), and cirrhosis results in about 20% of those with chronic infection, often several decades after initial exposure (Liang et al., 2000). In the United States, complications from the virus are the major cause of liver transplants, and HCV accounts for 40% of all chronic liver disease, and an annual death count of between 8000 and 10,000 (Centers for Disease Control and Prevention, 1998; Hoofnagle, 1997). In addition to the expected rapid rise in mortality from complications of HCV infection, the total health care costs attributed to HCV (estimated to have been over US$ 1 billion in 1998) are expected to skyrocket in the next several years (Kim, 2002). In spite of the serious potential consequences of chronic HCV infection and its high prevalence among drug users,

0376-8716/$ – see front matter © 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.drugalcdep.2003.08.009

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many individuals who use(d) drugs lack knowledge about the virus, and remain uniformed about their HCV status (Best et al., 1999; Dhopesh et al., 2000; Kwiatkowski et al., 2002; Stein et al., 2001). Counseling and screening for HCV infection is a critical strategy to limit the spread of the virus, and to help those already infected to maintain their health to the greatest extent possible (Zanetti et al., 2003). In particular, drug users who test HCV negative can be counseled about how to prevent contracting the virus. Those who test positive for HCV antibodies can be counseled about how to modify their behaviors in order to limit transmission, the importance of avoiding alcohol consumption, the variety of treatment options, and the wisdom of receiving hepatitis A and hepatitis B vaccinations (Gordon, 1999). In fact, some studies have shown that drug users who have more knowledge about HCV, and those who are aware of their HCV status, engage in fewer HCV-related risk behaviors (Heimer et al., 2002; Kwiatkowski et al., 2002). Unfortunately, because drug users are a medically underserved and a difficult-to-reach population (Bae, 1997; Chitwood et al., 1999; Contoreggi et al., 1998), HCV testing and counseling may not be readily available to them. Importantly, drug treatment programs are uniquely situated to provide comprehensive care for drug users (Des Jarlais et al., 1996; Needle et al., 1998; Polinsky et al., 1998; Selwyn et al., 1993), including screening for infectious diseases. Only a few studies, however, have examined the provision of HCV antibody testing in drug treatment programs. One study, reporting on a nationwide survey of HCV testing in 373 drug treatment programs in England and Wales, revealed that 70% of the programs provided HCV testing, but only 24% of them did so routinely (Winstock et al., 2000). Of the programs providing testing, 36.2% did so on-site, 59.8% did so through referral, and 4.1% provided testing both on-site and through referral. A survey of 109 drug treatment programs in New York City revealed that only half screened their patients for HCV infection (Pratt et al., 2002). While these studies are informative, they do not address a variety of salient issues associated with screening for HCV antibodies. In particular, while the need for HCV services may be greatest in methadone maintenance treatment programs—many of whose patients are (or were) drug injectors—these studies did not differentiate between methadone maintenance treatment programs and drug-free treatment programs in terms of their current and past practices regarding HCV antibody testing. In addition, while making HCV testing available to patients in drug treatment programs is critical so that drug users can learn their HCV status, its value is severely compromised if drug users do not agree to be tested. Studies involving HCV antibody screening demonstrate that many drug users do not capitalize on opportunities for testing (Aitken et al., 2002), including those offered this testing while patients in drug treatment programs (Grando-Lemaire et al., 2002; Smyth et al., 2000). Furthermore, research involving drug users’ utilization of medical care services while they

are patients in drug treatment programs indicates that they are more likely to utilize services that are provided on-site (e.g., Umbricht-Schneiter et al., 1994). No studies have compared the degree to which patients in drug-free as compared to methadone maintenance treatment programs accept testing for HCV antibodies, either on-site or off-site. In this paper, we report the findings of a study examining the accessibility and patients’ use of opportunities for HCV antibody testing in a nationwide sample (N = 256) of drug treatment programs in the United States. Because of the particular vulnerability of methadone maintenance treatment program patients to contract and transmit the virus, we compare methadone and drug-free treatment programs that currently provide HCV antibody testing in terms of (a) when and why they began offering the testing, (b) past 10 year trends in the offering of HCV testing, (c) their current practices concerning the offering of this testing, and (d) patients’ acceptance of this testing (to the extent that it is known by the drug treatment program). We also examine drug treatment programs’ recent changes and future plans concerning HCV antibody testing.

2. Method 2.1. Screening for eligibility and the sampling frame The research was conducted by initially screening for eligibility a random, nationwide sample of drug treatment units. By “drug treatment unit,” we mean a unit that primarily provides treatment on a one-to-one or on a group basis for drug (not only alcohol) abuse, dependence or addiction. All of these units were included in the 1 October 2000 Inventory of Substance Abuse Treatment Services (I-SATS), a comprehensive list (N = 17,160) of organized substance abuse treatment units known to the Substance Abuse and Mental Health Services Administration (SAMHSA) on that date. In telephone interviews with the units’ managers, we determined their eligibility for the research, including: location within the 50 United States and the District of Columbia; providing drug abuse treatment services on-site, and to at least 50% of their patients. Units that provided only detoxification or very short-term treatment (<7 days) were excluded. The screening questionnaire was enhanced to also obtain basic information about the HCV services provided by the unit, including an estimate of the proportion of patients tested for HCV antibodies in the past year. Drug treatment units were contacted sequentially and screened for eligibility according to the randomly ordered I-SATS list. Because of the predominance of past and present drug injectors in methadone maintenance treatment units (MMTUs), methadone units were deliberately over-sampled. In particular, from the randomly ordered I-SATS list, a separate database of treatment units was created that included only units known to have a license to dispense methadone, and units were contacted from this

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specially created list. Screening for eligibility for all units took place from January through October, 2001. In all, 42% of the 1286 units we attempted to contact were either not eligible for the research or could not be contacted by telephone after repeated attempts, and 10% opted not to participate in the survey research at the time they were screened for eligibility. A total of 614 units were determined to be eligible for the survey research and willing to consider participating in it (including 416 drug-free treatment units and 188 methadone units). All 614 of these units completed the enhanced screening questionnaire; they constitute the sampling frame for the survey research. 2.2. Survey research The comprehensive, 3 h computer-assisted telephone survey interview was written in Questionnaire Development System (QDS) software, Version 2.0 (NOVA Research Company, Bethesda, MD, 2001). Having received approval from the Institutional Review Board (IRB) at the National Development and Research Institutes, Inc., all survey interviews were preceded by assurances regarding the voluntary nature of the research and the confidentiality of responses. 2.2.1. The survey questionnaire The survey questionnaire included questions related to the units’ organizational structure and relationships with other organizations, finances, licensing and accreditation, the ideology of the director (especially regarding the innovation and implementation of HCV services), staffing, and patient demographics. It also included questions on the services provided by the unit, with an emphasis on health services (including medical referrals), especially as related to HIV and hepatitis C. Because the survey sought information that was often beyond the knowledge of any single person, it was divided into three sections, and generally involved separate interviews with the director, the staff supervisor, and the nurse (or the person most knowledgeable about the medical aspects of the unit). With regard to HCV antibody testing, the survey asked whether the unit offered this testing to any patients in the past year either on-site or off-site, and if not, why not. Respondents were also asked to estimate the proportion of their units’ patients who had been tested for HCV antibodies before being admitted to the treatment unit. If the unit offered HCV antibody testing, the survey asked when and why the unit began providing this service, the proportion of patients who were offered this testing in the past year, and whether the testing was offered at admission or during treatment. If some, but not all patients were offered testing for HCV antibodies in the past year, respondents were asked why this service was not offered to all patients, and what groups of patients were offered testing. The survey then asked about the proportion of patients who were actually tested, and of these, the proportion tested either on-site at the treatment unit or off-site at a facility affiliated with it. Finally, re-

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spondents were also asked about recent changes and future plans in their units’ policies regarding HCV antibody testing. While most of the questions were closed-ended, several were open-ended, giving respondents the opportunity to elaborate on some responses that benefited from further explanation. 2.2.2. Developing, pilot-testing, and finalizing the survey With the exception of questions concerning medical services, much of the survey was modified from the one developed and used by Thomas D’Aunno and co-workers in their National Drug Abuse Treatment System Survey (NDATSS) for outpatient substance abuse treatment programs (D’Aunno and Vaughn, 1995; D’Aunno et al., 1999). Survey sections involving medical services, especially those related to HIV and HCV, were created expressly for the research by the project team, together with its consultants. After developing a final draft of the survey questions, 25 drug treatment programs were involved in pilot-testing the data collection protocol, procedures, and the items themselves from October through December 2001. Based on information gathered during the pilot-testing phase, changes were made where necessary, and the final version of the survey questionnaire was implemented in January 2002. Data collection using this final version of the questionnaire continued through June, 2003. Because the items involving HCV antibody testing did not change from the pilot version, data from both the pilot and final versions of the survey are included in the current analyses. 2.2.3. Procedures Project interviewers contacted eligible units in order to encourage them to participate in the telephone-administered survey questionnaire. If a unit expressed interest in participating in the research, information about the project and a packet of worksheets were mailed to the unit’s director. The worksheets enabled respondents to gather some information in advance of the actual interview (e.g., year that HCV antibody testing began, proportion of patients tested in 2001 for HCV antibodies), information that might not be immediately known to the respondents. After allowing sufficient time for units to complete the worksheets, interviewers arranged appointments to conduct the surveys with unit managers and medical staff. Interviewers conducted the survey at times that were convenient for respondents, dividing the interview into as many sessions as necessary to accommodate the needs of the units’ respondents. A total of US$ 100 for respondents in each unit was offered as an incentive for completion of the survey, and as compensation for their time. 2.3. The study sample Since the time they were screened for eligibility from January through October 2001, 45 units were no longer eligible (in general, because they provided substance abuse treatment to fewer than half of their patients), and 90 either

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closed, or could not be reached or scheduled for an interview after repeated attempts. Thus, the sampling frame for the survey research was reduced from 614 to 479 units. In all, 291 units participated in the survey research. Although more units were interested in participating, they lacked the staff and time to commit to completing the worksheets and responding to the interview by the end of the data collection period. Of the 291 units that participated in the survey, 256 units completed the section on HCV antibody testing. In the 35 remaining units, the person most knowledgeable about HCV antibody testing was generally too busy to participate. These 256 units (including 161 drug-free units and 95 MMTUs) comprise the study sample. Based on their responses to the screening questionnaire, these 256 units treated a significantly larger mean number of patients each month (163 patients, S.D. = 167) than the remaining units in the original sampling frame of 614 units (130 patients, S.D. = 172; P = 0.018). These two groups of treatment units did not differ, however, with respect to operation by a hospital, membership in a network of units, private-for-profit ownership, treatment unit modality (i.e., residential versus outpatient), or number of staff with direct patient contact. In addition, the 256 treatment units in the study sample did not differ significantly from the remaining MMTUs and drug-free treatment units in the original sampling frame of 614 units in terms of the proportion of patients who were given an HCV antibody test while in the treatment unit during the past year.

Table 1 Characteristics of drug-free and methadone maintenance treatment units (MMTUs) Characteristic

Drug-free (N = 161)

MMTU (N = 95)

Ownership (%)∗∗∗ Public or private not-for-profit Private for profit

79.5 20.5

58.9 41.1

Network membership (%) Independent Part of a network

29.2 70.8

34.7 65.3

Operated by a hospital (%) Outpatient (%)a,∗∗∗ Estimated number of patients treated per month (mean, S.D.)∗∗∗ Number of staff providing direct patient services (mean, S.D.) Patient/staff ratio (mean, S.D.)∗∗∗

8.7 66.5 95 (105)

12.6 96.8 278 (187)

10.9 (15.1)

12.8 (8.5)

12.9 (12.4)

24.4 (12.3)

Estimated proportion of patients that ever injected drugs (%)∗∗∗ Up to 10% 54.8 1.1 Between 10 and 50% 43.3 26.3 More than 50% 1.9 72.6 a

We identify a unit as residential if the majority of its patients receive treatment in the residential component of the treatment unit. ∗∗∗ P < 0.001.

estimated that the majority of their patients ever inject(ed) drugs (P < 0.001). 3.2. Units that offered HCV antibody testing and those that did not

3. Results 3.1. Characteristics of MMTUs and drug-free units in the study sample Respondents for survey questions concerning HCV antibody testing primarily included nurses (or other medical staff), unit directors, and clinical supervisors. As can be seen in Table 1, the 95 MMTUs and 161 drug-free units in the study sample did not differ significantly with respect to their affiliation with a hospital (10.2% of the units), their inclusion in a network of units (68.8%), nor in the number of staff having direct contact with patients (12 staff, on average). MMTUs, however, were significantly more likely than drug-free treatment units to be outpatient (96.8% versus 66.5%, P < 0.001), private-for-profit (41.1% versus 20.5%, P < 0.001), served over two and a half times the number of patients each month (278 versus 95, P < 0.001), and had a patient staff ratio almost twice as large as that in the drug-free units (24.4 versus 12.9, P < 0.000). In addition, about half (54.8%) of the drug-free treatment units estimated the proportion of their patients who ever injected drugs to be under 10%, while only one (1.1%) of the MMTUs estimated its patient population to have fewer than 10% who ever injected drugs. Furthermore, only 1.9% of the drug-free treatment units, but about three quarters (72.6%) of the MMTUs

Of the 256 units in the study sample, 198 (77.3%) offered HCV antibody testing to at least some of their patients, a proportion that is only 12.9% less than the 231 units that offered HIV testing to at least some patients. There were no statistically significant differences in whether or not HCV antibody testing was offered according to census region (i.e., north, south, midwest, west) or according to population size of the city or town in which the drug treatment unit is located (i.e., under 15,000; 15,000–49,999; 50,000–199,999; 200,000 or more). MMTUs, however, were significantly more likely to offer this testing than drug-free treatment units (93.7% and 68.1%, respectively; P < 0.001). In the 58 units that did not provide this patient testing, the most frequently cited primary reason was lack of resources—both financial and personnel (48.3%). Most of the other units indicated that the primary reason for not providing this testing was either that they did not view their patients as being at risk for HCV infection (17.2%), or their view that the provision of this testing was not part of the unit’s mission (13.8%). Most of the remaining units cited a lack of awareness concerning the incidence of HCV and the importance of HCV antibody testing, the lack of a mandate to provide testing, or the lack of medical personnel. In addition, respondents indicated that some of their patients had already been tested for HCV antibodies before entering their treatment units. On average, 22.0% of

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1

Proportion of Programs

0.9 0.8

drug free

0.7

methadone

0.6 0.5 0.4 0.3 0.2 0.1 0 1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

Year

Fig. 1. Among units offering HCV antibody testing in the year 2001, trends in the proportion of drug treatment units offering this testing.

the patients in drug-free treatment units and 34.6% of the patients in MMTUs were estimated to have been tested in the past (P = 0.001). 3.3. When and why HCV antibody testing began Of the 198 treatment units that provided HCV antibody testing to at least some patients in 2001, less than one eighth of the units began offering this testing in 1992, the first year that a test for HCV antibodies was available (Waite, 1996). Of these 198 treatment units, Fig. 1 demonstrates that until the year 2000, a greater proportion of drug-free treatment units than MMTUs provided this testing. In fact, there was a tendency for these drug-free treatment units to begin offering this service to their patients 1 year earlier than the MMTUs, on average (P = 0.059). Table 2 lists the reasons why MMTUs and drug-free treatment units began offering testing for HCV antibodies. Some units did so because they viewed this testing as part of their unit’s mission (49.0%), or patients requested it (28.1%). A significantly greater proportion of drug-free treatment units than MMTUs indicated that they began providing this testing because there was a mandate (generally by the state) to do so (19.6% versus 9.0%, P = 0.037), while MMTUs were significantly more likely than drug-free units to begin providing this service because it was offered to the units at no cost, either as part of a research project or through the local health department (19.1% versus 5.5%, P = 0.003). Respondents were asked, in an open-ended format, to provide other reasons for why they began to offer HCV antibody testing. One-third of the units (33.8%) indicated that they began offering testing when they realized that their patients needed this service. One respondent indicated, for example, that “abnormal liver tests were showing that they needed it, and there was a lot of high risk behavior,” and another said, “we had a few patients with a history of hepatitis C, so we

thought it was a good idea to offer testing in case others had it and did not know.” In some cases, units began offering HCV antibody testing because staff or management had the virus: “we found out that a lot of the staff had it, since most of our staff are in recovery, and we thought we should test our patients,” and “I have hepatitis and I thought it would be best if we test our patients because of their risk behaviors.” In other cases, staff members were educated about HCV related needs for patients: “we knew that there was a high risk, and the research in the field helped us make this decision.” 3.4. When and to whom HCV antibody testing is currently offered As can be seen in Table 2, MMTUs were significantly more likely than drug-free treatment units to offer HCV antibody testing, both at admission to treatment (90.6% versus 65.2%, P < 0.001) and after the treatment admission phase (87.1% versus 71.9%, P = 0.014). In 76.1% of the MMTUs currently offering HCV antibody testing, and in 44.3% of the drug-free units offering this testing, all patients were offered this service (P < 0.001). Only some of the patients in these units who were offered HCV antibody testing actually agreed to be tested, however. To the extent that it is known by the drug treatment unit, 61.3% of the patients in drug treatment units that offered testing to all of their patients provided specimens for testing for HCV antibodies. Of these HCV antibody tests, a significantly greater proportion of those at MMTUs than at drug-free treatment units were conducted on-site or at a facility affiliated with the treatment unit (72.5% versus 52.8%, P = 0.025). In all, 82.4% of these patients who submitted specimens for antibody testing were given their test results by someone on-site at the treatment unit, generally (83.9%) within 2 weeks of the testing. In 92.9% of the units, preand post-test counseling was offered to these patients, most

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Table 2 Characteristics of drug treatment units that offered HCV antibody testing to patients in 2001 Characteristic

Drug-free (N = 109)

Years since began HCV antibody testing (mean, S.D.)#

5.45 (2.92)

MMTU (N = 89) 4.63 (2.58)

begana

Why HCV antibody testing Part of unit’s mission Realization of patients’ needs Patient request Mandate∗ Offered by outside agency (researchers, county, etc.)∗∗ Otherb

43.9 38.5 27.1 19.6 5.5 3.7

55.1 28.1 29.2 9.0 19.1 1.1

When HCV antibody testing is currently offered (in %) At admission∗∗∗ After the admission phase∗

65.2 71.9

90.6 87.1

Who is currently offered HCV antibody testing∗∗∗ All patients Some (not all) patients

44.3 55.7

76.1 23.9

Among units offering HCV antibody testing to all patients Proportion actually tested Of these, proportion of units that tested on-site at the unit, or its affiliate∗

54.4 52.8

65.9 72.5

23.6

42.0

34.3

43.2

Among units offering HCV antibody testing to some (not all) patients, proportion of patients offered testing∗∗ Relatives/partners of patients could access HCV antibody tests a

Respondents could provide more than one response. Includes recommendation by outside agencies (e.g., OASAS, department of health), identification of appropriate referral agency, increased resources dedicated to medical services. # P < 0.10. ∗ P < 0.05. ∗∗ P < 0.01. ∗∗∗ P < 0.001. b

often by a medical provider at the site (48.1%) or by the patients’ drug counselors (25.0%). In the remaining drug treatment units that only offered HCV antibody testing to some of their patients (i.e., 21 MMTUs and 61 drug-free units), a significantly greater proportion of patients in the MMTUs than the drug-free units were offered this testing (42.0% versus 23.6%, P = 0.009). The most frequently cited reasons given for not testing all patients in these units included a lack of resources for testing everyone (33.8%), a perception that not all patients were at risk (32.5%), and the lack of necessity to test all patients, primarily because some patients had been tested before (17.5%). Other reasons for not offering testing to all patients was a lack of request or a refusal on the part of some patients to be tested for HCV antibodies, and lack of knowledge concerning the importance of HCV antibody testing. The 82 units offering testing to some (but not all of their patients) were most likely to offer this testing to (a) patients who requested testing (83.8%), (b) patients who ever injected drugs (56.3%), (c) patients who were HIV+ (51.3%), (d) patients who had abnormal liver function tests (50.0%), and (e) partners of injection drug users (42.5%). In addition, in 38.3% of all of the units offering HCV antibody testing to at least some patients, relatives or partners

of patients were able to access HCV antibody testing either on-site or by referral through the treatment unit. 3.5. Recent changes and future plans concerning HCV antibody testing Nine of the drug-free units and ten of the MMTUs that offered testing for HCV antibodies in the year 2001 indicated that their policies for testing patients for hepatitis C had changed since that time. Changes at the drug-free units include instituting a more comprehensive evaluation to determine which patients are at risk for HCV, facilitating referral for testing for at-risk patients, providing transportation for testing, providing testing on-site, recommending testing for all patients at risk and providing transportation to the clinic to support this recommendation, and mandating testing for all patients. Past year changes in MMTUs regarding HCV antibody testing policies include providing free testing for families of patients and the general public, implementing on-site testing, testing more frequently (i.e., every 6 months), and testing all newly admitted patients, the latter a recent requirement for accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF). Two MMTUs, however, have stopped testing patients because the research project that funded this testing has ended, one

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no longer provides liver function tests as part of the medical exam at admission, and another provides testing less frequently due to decreased funding. Among the units that did not offer HCV antibody testing in the year 2001, one MMTU obtained a state grant to test all patients since that time. Five drug-free treatment units that did not offer HCV antibody testing in the year 2001 either began offering testing in 2002 or have been working with hospitals or clinics to arrange to institute this testing. Sixteen of the MMTUs and nine of the drug-free treatment units that offered patients antibody testing in the year 2001 had a plan in place to expand services to test patients for HCV antibodies over the course of the next year. Half of these 16 MMTUs planned to institute on-site testing. Other units planned to find a test site that will screen for HCV antibodies at minimal cost, test both at intake and annually, get involved in a research project to cover the cost of testing, and test more patients. The nine drug-free treatment units that offered patients HCV antibody testing in the year 2001 planned to obtain more HCV services by becoming involved in a research project, obtaining funding for testing from some other source, setting up an HIV/HCV co-infection clinic, affiliating with an outside clinic, or handling the testing themselves rather than referring out. In addition, four drug-free treatment units that did not offer HCV antibody testing in the year 2001 planned to test patients on-site, provide testing to all patients at admission, affiliate with a physician who will identify at risk patients, or prominently display information about where patients can go for testing.

4. Discussion Our analyses indicate that almost all MMTUs and about two-thirds of drug-free treatment programs surveyed offered HCV antibody testing to their patients in 2001. That a significantly greater proportion of MMTUs than drug-free treatment units in the United States offered such testing is understandable, given the large numbers of former and current drug injectors in those units compared with other treatment units. In addition, among units where this testing was provided, significantly more MMTUs offered it to all patients. It is of concern that, among units offering testing to only some of their patients, only about half of the units offered this service to individuals at especially high risk for contracting and transmitting HCV, including individuals who ever injected drugs, those who were HIV+ , those who had abnormal liver function tests, and sexual partners of injection drug users. Of even greater concern is the fact that some MMTUs and one-third of the drug-free treatment units did not offer this testing to any of their patients. The continuing high incidence of HCV among drug users, together with the high personal and financial costs of chronic HCV infection, suggest the critical need to screen and counsel patients for the hepatitis C virus.

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Examining the reasons why units began offering screening for HCV antibodies is useful, because it can illuminate ways to motivate an expansion of HCV antibody testing services in units that currently offer (at most) limited patient testing for HCV antibodies. Respondents in units where HCV antibody testing is currently offered indicated that the provision of HCV antibody testing was not primarily driven by mandates from the government or other outside agencies. Rather, initially implementing HCV antibody testing was generally the result of the treatment unit’s perspective that this testing is part of its mission, or the result of reacting to patients’ needs, either as observed by the units’ managers or requested by the patients, themselves. Thus, treatment unit managers may need to be educated about the importance of this screening for all patients, including those who have tested negative for HCV antibodies in the past. Because many former injectors may resume drug injection in the future, and others who sniff(ed) or smoke(d) drugs may become drug injectors, all drug treatment unit patients can benefit from the education and counseling that accompany HCV antibody testing. Certainly, a major obstacle to implementing HCV antibody testing or offering it to more patients in drug treatment units is limited resources. Some units, especially MMTUs, began providing HCV antibody testing as a result of participation in a research project, or availing themselves of testing opportunities provided through the health department. Units that want to screen patients for HCV antibodies but lack the resources to do so may find such linkages helpful. Unfortunately, offering patients testing for HCV antibodies does not necessarily mean that they will agree to be tested. Our results indicate that, to the extent that it is known by the treatment units, patients agree to be tested in only about two thirds of the MMTUs and about half of the drug-free units that offer testing to all patients. While the proportions of patients who were actually tested may be somewhat underestimated (because, unknown to the units, some additional patients may have submitted specimens for HCV antibody testing), there appears to be a considerable gap between units’ offering and patients’ use of this service. MMTUs’ awareness of the importance of offering this testing may be reflected in the fact that, unlike drug-free treatment units, the vast majority of MMTUs offer this testing both at the time of admission and during treatment. The majority of HCV antibody tests for these patients were conducted on-site or at a facility affiliated with the treatment unit. Thus, the availability of testing opportunities, and the ease of accessibility of this testing may be helpful in encouraging greater patient acceptance of HCV antibody testing. Our data suggest that more units in the United States, especially MMTUs, have initiated or increased HCV antibody testing services, and others have plans to do so. Indeed, our data show that there has been a marked increase among MMTUs, especially since the year 1999, in the proportion of units that offer HCV antibody testing. Recent or planned

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changes include: offering testing to more patients; providing testing for families of patients (a practice already in place in about one-third of the units that offer patient testing); providing testing on-site or facilitating testing by arranging transportation to testing sites; and linking up with hospitals, pharmaceutical companies, research projects, clinics or local health departments to reduce the costs of testing. Outside agencies may also be instrumental in increasing the provision of HCV antibody screening in MMTUs. In fact, several MMTUs indicate that in order to gain accreditation from CARF they must screen all newly admitted patients for HCV antibodies. Limited resources, however, may continue to prevent some units from offering testing services, as evidenced by two MMTUs that reported having to stop testing patients because the research projects that funded this testing have ended. Although this paper advocates for the provision of HCV antibody testing for all patients in drug treatment units, there are drug treatment providers who question the value of testing patients for previous HCV exposure. Relatively speaking, the cost of this testing is not exorbitant, but these providers may view the use of resources for this purpose as preventing the implementation of other services they deem to be more essential. Units whose patient populations include few drug injectors may especially question this use of limited treatment unit funds. In addition, many units and individual patients do not have the resources to (a) follow up a positive HCV antibody test with HCV-RNA tests or liver biopsies to determine the degree to which the infection is persistent and has compromised the liver, and (b) finance medical treatment for chronic HCV infection, when indicated. Furthermore, current medication protocols for chronic HCV induce a sustained virological response in only 40–50% of patients with genotype 1, the most common genotype in the United States (Fried et al., 2002; Manns et al., 2001). In addition, these medications often have side effects, especially depression and anemia, which may be especially difficult for people in recovery to tolerate (Fried et al., 2002; Manns et al., 2001). Thus, some thoughtful and caring treatment providers worry that testing for HCV antibodies may open a Pandora’s box for some patients who test HCV antibody positive. Patients burdened with knowledge that they may have a chronic infection, but who are unable to effectively address the consequences of this knowledge may suffer unnecessary stress. While we respect this viewpoint, we believe that, on balance, the benefits of testing for HCV antibodies and learning the results of this testing outweigh the drawbacks. As we have argued, counseling and screening for HCV infection is a potentially important approach to contain the spread of the virus, and to help those already infected learn how to best maintain their health. Whenever, possible, however, we would recommend that the timing of this testing, relative to admission to treatment, be determined on an individual basis. Some patients may simply be too unstable to address the consequences of a positive HCV antibody

test result in the first days and weeks in the drug treatment unit. There are a number of limitations to the research that should be acknowledged. First, although respondents were asked to complete worksheets eliciting information about HCV antibody testing before the actual interview, some respondents did so more diligently than others. In addition, drug treatment units may not always have been aware that some patients were actually tested for HCV antibodies. Thus, the accuracy of the responses to some of the questions is likely to have varied. Results may therefore be biased by socially desirable responses that inflate the proportion of individuals offered and/or accepting HCV antibody testing, or underestimating these proportions because of respondents’ lack of awareness of true percentages. Second, the data reflect the provision of HCV related services by drug treatment units as reported by a program administrator or medical staff member. Because patients at the treatment units were not interviewed, we are unable to report patients’ perceptions of the adequacy or quality of these services. Finally, there is the possibility that non-participating units differ in some important ways from those that did participate, thus introducing unknown bias in research results. The 256 units in the study sample, however, do not differ from the remaining units in the sampling frame in terms of a variety of organizational characteristics. Importantly, the units in the study sample also do not differ from the non-participating units in terms of the proportion of patients given HCV antibody testing while in the treatment unit during the past year. Thus, these 256 units appear to be generally representative of the units in the sampling frame in terms of the issues concerning HCV antibody testing, but it is difficult to know for certain. This study provides important information concerning HCV antibody testing for patients in MMTUs and drug-free treatment units, a strategy that we argue is a critical component in the response to the HCV epidemic among drug users. The study also supports the need to conduct further research that examines how drug treatment units can be encouraged to implement or expand their capacity to offer screening to more patients for HCV antibodies, and to encourage more patients to avail themselves of this potentially life-saving service.

Acknowledgements Funding for this study was provided by the National Institute on Drug Abuse (grant no. 1-R01 DA13409). Points of view do not represent the official positions of the Federal government, NIDA, or NDRI. We especially wish to thank Deborah Trunzo, of the Office of Applied Studies, SAMHSA, for her kind assistance in arranging for the project’s use of the I-SATS database. We also thank Lelia Cahill, Sarah Krassenbaum, Kim Sanders, and Kristine Ziek, the project interviewers. Finally, we are grateful to

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the survey respondents, many of whom devoted a considerable amount of time in already overextended schedules to provide thoughtful responses to our questions.

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