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Delivery of HIV risk-reduction services in drug treatment programs
Journal of Substance Abuse Treatment 19 (2000) 229–237
Article
Delivery of HIV risk-reduction services in drug treatment programs Christine E. Grella, Ph.D.a,*, Rose M. Etheridge, Ph.D.b, Vandana Joshi, Ph.D.a, M. Douglas Anglin, Ph.D.a a
Drug Abuse Research Center, Neuropsychiatric Institute, University of California, Los Angeles, 1640 S. Sepulveda Boulevard, Suite 200, Los Angeles, CA 90025, USA b National Development and Research Institutes, Inc., Raleigh, NC, USA Received 9 July 1999; accepted 10 November 1999
Abstract This study examined services received for HIV risk reduction among individuals in drug treatment. Analyses were conducted using data from 4,412 participants in the national Drug Abuse Treatment Outcome Study (DATOS), a prospective multisite study of drug treatment effectiveness. A higher percentage of individuals in long-term residential programs received HIV-related services, compared with clients in short-term inpatient, methadone maintenance, and outpatient drug-free programs. More men than women, and individuals at higher sex-risk as compared with those at lower sex-risk, received HIV services. Logistic regression analyses indicated that individuals who engaged in sex work had a higher likelihood than those who did not, of receiving HIV-related services, although individuals with high-risk or multiple sexual partners were no more likely than others to receive HIV services. More comprehensive service delivery is needed in order to reduce the risk for HIV among clients in drug treatment. © 2000 Elsevier Science Inc. All rights reserved. Keywords: HIV services; HIV risk reduction; Treatment modality; Gender; Sex risk
1. Introduction The transmission of HIV among drug users has dramatically enlarged the scope of drug treatment in order to address the risk of HIV among individuals in treatment (Brown, 1990–91; Brown & Beschner, 1989; Brown & Needle, 1994; Sorensen & Miller, 1996; Watters, 1996). Treatment providers now offer a wider range of services that encompass HIV education and prevention interventions, such as HIV testing and counseling, general education regarding HIV, and promotion of risk-reduction practices. One study showed that outpatient substance abuse treatment units significantly increased their HIV prevention efforts, particularly in regard to injection drug users, from 1988 to 1995 (D’Aunno et al., 1999). Prior research has demonstrated that drug treatment is associated with increases in HIV-related knowledge (Malow & Ireland, 1996; Sorensen et al., 1994) and reductions in drug use and high-risk injection behaviors (Baker et al., 1993; Ball & Ross, 1991; Ball et al., 1988; Boatler et al., 1994; Broome et al., 1999; Dengelegi et al., 1990; Metzger et al., 1993; Saxon & Calsyn, 1992), especially among opiate users
* Corresponding author. Tel.: 310-445-0874, x243; fax: 310-473-7885. E-mail address: [email protected] (C.E. Grella).
in methadone maintenance treatment. Stimulant users have been shown to increase safer sex practices subsequent to participation in drug treatment (Shoptaw et al., 1997, 1998), although high-risk sexual behaviors have been more resistant to change among drug users (Battjes et al., 1995). The delivery of drug treatment services varies across types of drug treatment programs. Historically, drug treatment programs have been categorized according to type of treatment modality (Cole & James, 1975; Etheridge et al., 1997); for example, pharmacotherapeutic approaches, such as methadone maintenance treatment for opiate addiction, have been distinguished from outpatient drug-free treatment. Similarly, therapeutic communities, which are longterm community-based residential programs, have been differentiated from hospital-based inpatient programs, which typically provide treatment for less than 30 days, often limited to detoxification. Not only do the types of individuals entering into these different kinds of drug treatment programs vary in terms of their drug use history and severity, their prior treatment history, and other individual characteristics (Anglin et al., 1997), but treatment intensity, expected duration, and process typically differ across the treatment modalities (Etheridge et al., 1997). It is important, then, to distinguish among these types of treatment modalities when examining the delivery of HIV risk-reduction services within drug treatment programs.
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C.E. Grella et al. / Journal of Substance Abuse Treatment 19 (2000) 229–237
Furthermore, the delivery of HIV services within programs may be influenced by the characteristics of individuals entering into drug treatment. Although the risk for HIV is likely to vary by gender, it is unclear whether treatment programs are tailoring HIV risk-reduction interventions to address the specific needs of men and women drug users. Women drug users may be differentially at risk for HIV infection, compared with men, because of the nature of their drug use and sexual behavior (Amaro, 1995; Hartel, 1994; Wells & Jackson, 1992). Women injection drug users (IDUs) are more likely than men to share injection equipment with others, particularly their spouse or sexual partners, and to be affected by others’ needle-cleaning practices (Wayment et al., 1993). Moreover, women IDUs are more likely than men to have sexual relations with other IDUs and to exchange sex for money or drugs (Booth et al., 1995). Yet to be determined is whether HIV risk-reduction interventions as typically provided reach those individuals who are most at risk for HIV infection. In particular, individuals who engage in high-risk sexual behaviors may not be adequately assessed or targeted for HIV risk-reduction services when they enter drug treatment. Since the sexual behaviors that put individuals at risk for HIV infection are either stigmatized (e.g., men who have sex with men), illegal (e.g., sex work), or considered to be private issues concerning one’s personal relationships (e.g., number and type of sexual partners, use of condoms), individuals who enter drug treatment may fail to self-disclose these high-risk sex behaviors and program staff may neglect to question them or to probe for more detail. Concerns about confidentiality and privacy, which are heightened with regard to HIV, may prevent staff from identifying high-risk individuals who would benefit from HIV risk-reduction interventions. The goal of this study was to evaluate the extent of services received for HIV risk reduction among clients in drug treatment across four different types of treatment modalities, to examine gender differences in HIV services received, and to determine whether individuals who are at higher sex-related risk for HIV are more likely than others to receive HIV services. Analyses were conducted using the national Drug Abuse Treatment Outcome Study (DATOS), a prospective multisite study of drug treatment effectiveness sponsored by the National Institute on Drug Abuse.
2. Method
patient drug-free programs (ODF) (see Flynn et al., 1997 for a description of the DATOS methodology). The intake assessment consisted of two 90-minute interviews: Intake 1 was administered at admission to treatment or shortly thereafter, and Intake 2 was completed after about 7 days of treatment. Intake 1 primarily obtained baseline data on background characteristics; Intake 2 provided information for clinical assessment. Interviews were conducted with clients after 1 and 3 months in treatment or aftercare about the services they had received. 2.2. Subjects Subjects for the study reported in this paper included 2,911 men and 1,501 women who completed both Intakes 1 and 2 and an in-treatment interview at either 3 months (LTR, ODF, and OMT) or 1 month (STI). We used a listwise deletion of cases who were missing data on any of the variables used in the analyses, which are described below. Among the subjects included for analysis in this study, two thirds (66%) were male and the overall mean age was 32.6 years (SD ⫽ 7.6). The gender and age distributions within modalities were similar to the overall sample, except that clients in OMT were older with a mean age of 37 years (SD ⫽ 7.4). About two fifths (44%) were African American, 41% were White, 13% were Hispanic, and the remainder (2%) were either Asian or “other.” Ethnic distributions within modalities were proportionately similar, with the exception of OMT, where more of the clients were White and fewer were African American. The sample consisted mainly of high school graduates (39%) and individuals with 9–12 years of school (35%). About one half of the sample was employed during the 12 months prior to admission to the DATOS treatment episode. Only 31% were presently married or living with a partner. The majority of the clients at intake (52%) reported cocaine as their primary problem drug and approximately one fifth (19%) reported heroin. Primary problem drug varied by modality, with 80% of the clients in OMT reporting heroin as their primary drug problem. In contrast, about two thirds of the clients in LTR and STI programs and one half of the clients in ODF programs reported cocaine as their primary problem drug. Approximately, two fifths of the sample was dependent on alcohol. DATOS was the first drug treatment episode for about half of the sample. Additionally, one third had antisocial personality disorder and 12% had a lifetime diagnosis of major depressive disorder.
2.1. DATOS data collection DATOS is a comprehensive multisite prospective study of drug treatment effectiveness (Fletcher et al., 1997). A population of 10,010 DATOS clients has been interviewed at entry to treatment in a sample of 96 programs within the United States from 1991 to 1993. Clients were selected from four drug treatment modalities: 3,122 clients from 14 short-term inpatient programs (STI), 2,774 clients from 21 long-term residential programs (LTR), 1,540 clients from 29 outpatient methadone treatment programs (OMT), and 2,574 clients from 32 out-
2.3. Variables Variables were chosen for the analysis in order to test the hypothesis that individuals who engage in high-risk sexual behaviors would be more likely to receive HIV services in drug treatment programs, while controlling for other relevant subject characteristics, including gender. The construction and coding of the variables used in this analysis are summarized below. All dichotomous variables were coded with 1 ⫽ yes and 0 ⫽ no, unless indicated.
C.E. Grella et al. / Journal of Substance Abuse Treatment 19 (2000) 229–237
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2.3.1. Demographic/background characteristics This domain included variables for gender, age, ethnicity (dummy variables for African American, Latino, and “other,” with White as the reference category), educational status (high school degree ⫽ 0, college degree ⫽ 1, with less than a high school degree as the reference category), and marital status (currently married or living as married ⫽ 1, not married ⫽ 0). Full-time work referred to employment in the year prior to treatment (employed ⫽ 1, unemployed ⫽ 0). A dichotomous variable measured whether treatment in the DATOS episode was covered partially or in full by health insurance.
2.3.9. HIV services Receipt of HIV-related services was based on self-report. Clients were asked whether they had received any type of HIV-related service while in treatment and, if so, the type of service received (i.e., needle-risk reduction, sex-risk reduction, health-care options for HIV/AIDS, and general information on HIV/AIDS); whether HIV risk reduction was identified as a treatment goal; and whether issues regarding HIV risk were discussed in individual counseling or group sessions.
2.3.2. Drug and alcohol dependence Separate dichotomous variables measured dependence on heroin, cocaine, and alcohol. Dependence was defined as meeting criteria from the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIII-R; American Psychiatric Association, 1987) for lifetime dependence. In addition, a dichotomous variable indicated whether the individual had injected drugs in the year prior to entering treatment.
First, differences in receipt of HIV services by type of DATOS treatment modality, gender, and sex-risk status were examined using chi-square analyses. Next, separate logistic regression models were constructed for the total sample and for each of the four modalities to examine whether individuals who engaged in high-risk sexual behavior were more likely to receive any type of HIV-related services, controlling for other subject characteristics. All analyses were conducted using SPSS (Norušis, 1992).
2.3.3. Prior drug treatment This variable indicated whether or not the client had ever received treatment for a drug problem prior to entering DATOS.
3. Results
2.3.4. HIV test Subjects were asked whether or not they had ever been tested for HIV, however, they were not asked to report test results. 2.3.5. Illegal activity Individuals were asked how many illegal activities they had engaged in within the prior 12 months prior to treatment entry; the sum was reported as a continuous variable. 2.3.6. Psychiatric status Three separate variables indicated whether individuals met the DSM-III-R criteria for a diagnosis of antisocial personality disorder, general anxiety disorder, or major depressive disorder. 2.3.7. Sex risk Sex risk was measured by three dichotomous variables: whether they had exchanged sex for money or drugs in the 12 months prior to entering treatment; whether they had a high-risk sex partner (defined as a sex partner who was HIVpositive, a man who has sex with men, a sex worker, or an injection drug user); and whether they reported having had two or more sex partners in the previous 12 months without always using a condom. A dichotomous composite sex-risk variable was constructed combining responses to these items, with a positive response on any of the three items coded as 1 (high risk), and others coded as 0 (low risk). 2.3.8. Modality The DATOS treatment modality was indicated by three dichotomous variables, one each for LTR, STI, and OMT, with ODF as the reference category.
2.4. Statistical analysis
3.1. HIV-related services received by clients by drug treatment modality and gender Overall, 17% of the clients reported that HIV risk reduction was identified as a treatment goal, 33% discussed HIV risk in individual counseling sessions, and 44% discussed HIV risk in group sessions. Table 1 provides information on the HIV services received by modality. LTR programs had the highest proportion of clients (86%) who received an HIV-related service during the first 3 months of treatment, 2(3) ⫽ 548.8, p ⬍ .001. A majority (60%) of the clients in STI programs reported receiving HIV services during 1 month of treatment, although fewer than half of the clients in OMT and ODF reported receiving an HIV-related service during the first 3 months of treatment. Approximately twice as many individuals in LTR and OMT reported that HIV risk reduction was identified as a goal in their treatment plan as compared with individuals in STI and ODF, 2(3) ⫽ 99.4, p ⬍ .001. Over half of the clients in OMT reported that HIV risk was discussed in individual counseling sessions, compared with about one third or fewer of the clients in the other modalities, 2(3) ⫽ 282.8, p ⬍ .001. Conversely, fewer clients in OMT reported discussing HIV risk in group sessions, which was more commonly reported by clients in the other modalities, 2(3) ⫽ 77.5, p ⬍ .001. When examined by type of HIV-related service received, clients in all modalities most often reported having received general knowledge about HIV; they less frequently reported receiving information on needle-risk reduction, sex-risk reduction, or health-care options for HIV/AIDS. Over half of the clients in LTR treatment reported receiving information on needle-risk reduction, as compared with approximately 30–
43.0 49.8 38.6 91.7 42.0 47.1 36.4 90.9 43.5 51.1 39.7 92.1 42.4 52.0 30.4 91.7 41.7 50.0 30.8 91.7 42.8 52.9 30.2 91.8 37.7 38.2 29.2 88.0 29.3** 29.9** 25.6 89.0 43.8 44.3 31.9 87.2 30.9 41.0 19.0 91.8 34.7 43.1 16.0 90.5 Gender differences significant at * p ⭐ .05, **p ⭐ .01. All differences by modality for the total sample are significant at p ⭐ .05. b
55.0 58.6 61.5 91.9 55.1 61.2 60.5 93.6
55.0 60.4 60.8 93.1
60.6 17.3 33.5 43.9 (N ⫽ 2,642) 57.8** 16.4 34.0 42.6 (n ⫽ 855) 62.1 17.8 33.3 44.6 (n ⫽ 1,787) 44.0 11.1 34.2 48.7 (N ⫽ 375) 40.3 9.7 32.3 45.3 (n ⫽ 120) 46.0 11.9 35.1 50.5 (n ⫽ 255) 43.3 21.0 53.6 31.6 (N ⫽ 390) 45.3 19.8 50.5 35.2 (n ⫽ 164) 41.9 21.9 55.7 29.2 (n ⫽ 226) 60.0 12.4 19.9 48.8 (N ⫽ 836) 58.1 10.7 19.0 43.7* (n ⫽ 262) 60.4 13.3 20.4 51.3 (n ⫽ 574) 83.4 25.3 37.5 46.2 (n ⫽ 309) 87.3 24.1 32.4 43.2 (n ⫽ 732)
86.1 24.5 34.0 44.1 (N ⫽ 1,041)
29.1 40.1 20.4 92.3 a
Services
Short-term inpatient
Table 1 HIV services received by gendera and type of treatment modalityb (%)
High-risk sexual activity was compared for men and women. A larger proportion of women reported having exchanged sex for drugs or money in the 12 months prior to treatment entry (30% vs. 6%), 2(1) ⫽ 448, p ⬍ .001, but about equal proportions of men and women reported having a high-risk sexual partner (approximately 30%) or having two or more sexual partners without always using a condom (approximately 40%). The composite measure of high-risk sexual status indicated that 50.7% of men and 55.1% of women were classified as having high sex-risk for HIV. Data on the receipt of HIV-related services by gender, sex-risk status, and modality are summarized in Table 2. Information on high-risk men is presented in the upper part of the table. Across all modalities, a larger proportion of high sex-risk as compared with low sex-risk men received HIVrelated services (66% vs. 58%), 2(1) ⫽ 20.5, p ⫽.001. More high sex-risk men also had HIV risk reduction specified as a treatment goal (19% vs. 16%), 2(1) ⫽ 5.3, p ⬍ .05, and discussed HIV risk within group sessions (47% vs. 42%), 2(1) ⫽ 8.7, p ⬍ .01. Among men who received HIV services in STI, fewer high sex-risk men received information on needle-risk reduction (25% vs. 33%), 2(1) ⫽ 4.3, p ⬍ .05, and health-care options (16% vs. 26%), 2(1) ⫽ 8.6, p ⬍ .01. Information regarding receipt of HIV services by women of high and low sex-risk status is shown in the lower half of Table 2. Across all modalities, a greater proportion of high sex-risk women received HIV services (62% vs. 52%), 2(1) ⫽ 15.3, p ⫽.001, and discussed HIV risk within group sessions (45% vs. 40%), 2(1) ⫽ 3.8, p ⫽.05. Among women who received HIV services in STI, a smaller proportion of high sex-risk women received information on needle-risk reduction (29% vs. 43%), 2(1) ⫽ 5.6, p ⬍ .05, sex-risk reduction (37% vs. 50%), 2(1) ⫽ 4.2, p ⬍ .05, and health-care options (12% vs. 22%), 2(1) ⫽ 5.0, p ⬍ .05. Among women in OMT who received HIV services, fewer high sex-risk women received information on needle-risk reduction (22% vs. 38%), 2(1) ⫽ 4.9, p ⬍
Outpatient methadone
3.2. HIV services received by gender, sex-risk status, and drug treatment modality
Received HIV-related services Risk reduction from AIDS as a goal in treatment plan Discussed risk of HIV infection in individual sessions Discussed risk of HIV infection in group sessions Among those who received any service: Type of HIV services received Reduce needle risk Reduce risk of sex transmission Health-care options for AIDS General knowledge about HIV
Outpatient drug-free
Total
40% of the clients in the other three modalities, 2(3) ⫽ 116.4, p ⬍ .001. About one half of the clients who received HIV services said that they received information on sexual risk reduction, with LTR having the largest (60%) and OMT the fewest (38%) number of clients who received this information, 2(3) ⫽ 94.4, p ⬍ .001. Twice as many clients in LTR treatment as those in the other modalities reported receiving information on health-care options for HIV/AIDS, 2(3) ⫽ 376.9, p ⬍ .001. Information on gender differences in HIV services received is also shown in Table 1. Overall, a higher proportion of men than women reported receiving HIV-related services (62% vs. 58%), 2(1) ⫽ 7.5, p ⬍ .01. In addition, in OMT more men received information on needle-risk reduction (44% vs. 29%), 2(1) ⫽ 8.6, p ⬍ .01, and on sexual transmission (44% vs. 30%), 2(1) ⫽ 8.3, p ⬍ .01.
Men Women Total Men Women Total Men Women Total Men Women Total Men Women Total (n ⫽ 855) (n ⫽ 379) (N ⫽ 1,234) (n ⫽ 957) (n ⫽ 458) (N ⫽ 1,415) (n ⫽ 544) (n ⫽ 364) (N ⫽ 908) (n ⫽ 555) (n ⫽ 300) (N ⫽ 855) (n ⫽ 2,911) (n ⫽ 1,501) (N ⫽ 4,412)
C.E. Grella et al. / Journal of Substance Abuse Treatment 19 (2000) 229–237
Long-term residential
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233
Table 2 HIV services received by gender, risk status and type of modality (%) Long-term residential Short-term inpatient
Outpatient methadone Outpatient drug-free
Total
Services
High risk
High risk
High risk
Men Received HIV-related services Risk reduction from AIDS as a goal in treatment plan Discussed risk of HIV infection in individual sessions Discussed risk of HIV infection in group sessions Among those who received any service: Type of HIV services received Reduce needle risk Reduce risk of sex transmission Health care options for AIDS General knowledge about HIV Women Received HIV-related services Risk reduction from AIDS as a goal in treatment plan Discussed risk of HIV infection in individual sessions Discussed risk of HIV infection in group sessions Among those who received any service: Type of HIV services received Reduce needle risk Reduce risk of sex transmission Health care options for AIDS General knowledge about HIV
(n ⫽ 502) (n ⫽ 353) (n ⫽ 486) (n ⫽ 471) (n ⫽ 251) (n ⫽ 293) (n ⫽ 241) (n ⫽ 314) (n ⫽ 1,480) (n ⫽ 1,431) 89.2 84.4* 61.9 58.8 44.2 39.9 49.0 43.6 66.1 57.9*** 24.1
Low risk
24.1
High risk
16.1
Low risk
10.4**
25.5
Low risk
18.8
High risk
10.0
Low risk
13.4
19.4
Low risk
16.1*
31.9 34.8 27.2 15.3*** 58.6 53.6 32.8 37.9 35.0 44.6 41.1 53.7 48.8 36.3 23.2*** 51.5 50.0 47.3 (n ⫽ 443) (n ⫽ 289) (n ⫽ 300) (n ⫽ 274) (n ⫽ 111) (n ⫽ 115) (n ⫽ 118) (n ⫽ 137) (n ⫽ 972)
32.9 41.9** (n ⫽ 815)
56.9 63.0 60.7 93.7 (n ⫽ 263) 84.0
52.3 58.5 60.2 93.4 (n ⫽ 116) 81.9
43.7 51.0 39.0 92.9 (n ⫽ 828) 62.3
43.3 51.2 40.5 91.2 (n ⫽ 673) 52.3***
25.9
24.1
17.0
15.6
25.3 37.0 15.7 93.7 (n ⫽ 237) 62.9 9.3
33.2* 43.4 25.6** 91.0 (n ⫽ 221) 52.9*
40.5 40.5 26.1 90.1 (n ⫽ 199) 43.7
47.0 47.8 37.4 84.4 (n ⫽ 165) 47.3
44.1 51.8 28.8 90.7 (n ⫽ 129) 45.7
12.2
17.6
22.4
12.4
41.6 54.0 31.4 92.7 (n ⫽ 171) 36.3 7.6
41.4 31.0 44.9 49.1 (n ⫽ 217) (n ⫽ 92)
22.8 16.3 48.7 47.3 39.8 40.7 (n ⫽ 147) (n ⫽ 115) (n ⫽ 87)
53.3 28.5* (n ⫽ 77)
29.5 46.5 (n ⫽ 58)
34.5 44.4 (n ⫽ 62)
36.0 44.8 (n ⫽ 509)
32.5 39.8* (n ⫽ 346)
56.2 58.1 58.5 91.2
28.6 37.4 11.6 91.2
37.7* 37.7* 39.0*** 88.3
51.7 55.2 36.2 91.4
32.3* 45.2 25.8 91.9
41.8 45.8 34.8 91.0
42.2 49.1 38.7 90.8
52.2 59.8 68.5 93.5
42.6* 50.4* 21.7* 89.6
21.8 23.0 13.8 89.7
*p ⭐ .05, **p ⭐ .01, *** p ⭐ .001
.05, sex-risk reduction (23% vs. 38%), 2(1) ⫽ 4.2, p ⬍ .05, and health-care options for AIDS (14% vs. 39%), 2(1) ⫽ 13.6, p ⫽ .001. Among women in ODF who received HIV services, more high sex-risk women received information on needle-risk reduction (52% vs. 32%), 2(1) ⫽ 4.7, p ⬍ .05. 3.3. Logistic regression models for HIV services received by drug treatment modality In order to determine which subject characteristics, including high-risk sexual behaviors, increased the likelihood of receiving HIV-related services, separate logistic regression models were constructed for the total sample and for each modality. Each of the three sex-risk variables (i.e., having two or more sex partners without always using condoms, having a high-risk sex partner, engaging in sex work) was entered separately into the models to test whether they were differentially related to the receipt of services. These data are summarized in Table 3. 3.3.1. Total sample Men were 24% more likely than women to receive HIV services. African Americans and Hispanics were more likely than Whites to receive HIV-related services. Individuals who were employed or who had health insurance were less likely than unemployed or uninsured individuals, respectively, to receive HIV-related services. Individuals diagnosed with antisocial personality disorder, alcohol dependence, or cocaine dependence were more likely than their respective comparison groups to receive HIV-related services, however, those diagnosed with heroin dependence
were less likely. Individuals who engaged in sex work were approximately 50% more likely to receive HIV-related services, although individuals with high-risk or multiple sex partners were no more likely than others to receive these services. Individuals who had a prior HIV test, had prior drug treatment, or who had engaged in more illegal acts were all marginally more likely to receive HIV services. 3.3.2. Long-term residential programs African Americans and Hispanics were more likely than Whites to receive HIV-related services in this modality. Individuals who were unemployed, did not have health insurance, or had major depressive disorder were marginally more likely to receive HIV-related services. 3.3.3. Short-term inpatient programs African Americans and individuals of “other” ethnic groups were more likely than Whites to receive HIV services, as were individuals who had a diagnosis of major depressive disorder, were alcohol-dependent, engaged in sex work, or had taken a prior HIV test. Individuals with generalized anxiety disorder were marginally less likely to receive HIV-related services. 3.3.4. Outpatient methadone treatment programs African Americans and Hispanics were more likely than Whites to receive HIV-related services and individuals who were employed were less likely than unemployed individuals. Individuals with antisocial personality disorder were marginally more likely to receive these services.
– – – –
Male Married Age Education Level African American (referent ⫽ White) Hispanic (referent ⫽ White) Other ethnic group (referent ⫽ White) Full-time employed Has health insurance Major depressive disorder General anxiety disorder Antisocial personality disorder Alcohol-dependent Cocaine-dependent Heroin-dependent Injection drug use Sex work High-risk sex partner Multiple sex partners without condom use HIV test Prior drug treatment Number illegal acts 0.77 0.69
– – – – 2.16**** 1.99** – 1.39* 0.70* 1.73* – – – – – – – – – – – –
OR – – – – 1.40, 3.32 1.18, 3.37 – 0.97, 2.04 0.48, 1.04 0.91, 3.18 – – – – – – – – – – – –
95% CI
0.48 0.87 – ⫺0.40 0.38 ⫺0.55 – 0.25 – – – 0.45 – – 0.46 – –
–
– – – –
B – – – – 1.62**** – 2.39** – 0.67*** 1.46** 0.58* – 1.29** – – – 1.57** – – 1.58**** – –
OR
Short-term inpatient (n ⫽ 1,217) – – – – 1.19, 2.06 – 1.05, 5.44 – 0.52, 0.90 1.01, 2.12 0.31, 1.02 – 1.00, 1.66 – – – 1.06, 2.32 – – 1.23, 2.04 – –
95% CI
0.87 0.44 – ⫺0.74 – – – 0.31 – – – – – – – – – –
– – – –
B – – – – 2.39**** 1.56** – 0.48**** – – – 1.37* – – – – – – – – – –
OR – – – – 1.63, 3.43 1.01, 2.30 – 0.34, 0.69 – – – 1.00, 1.87 – – – – – – – – – –
95% CI
Outpatient methadone (n ⫽ 820)
Note: B ⫽ regression coefficient; OR ⫽ odds ratio; CI ⫽ confidence interval; – Indicates variable was nonsignificant in the model. *p ⬍ .10, **p ⭐ .05, ***p ⬍ .01, ****p ⬍ .001.
0.33 ⫺0.36 0.55 – – – – – – – – – – – –
–
B
Variable
Long-term residential (n ⫽ 1,083)
Table 3 Logistic regressions predicting receipt of HIV services by drug treatment modality
0.49 – – – – – – ⫺0.55 – – – – 0.40 0.35 – ⫺0.50 0.56 – – – – –
B 1.62** – – – – – – 0.58*** – – – – 1.49** 1.43* – 0.61** 1.75* – – – – –
OR
1.09, 2.39 – – – – – – 0.40, 0.77 – – – – 1.04, 2.10 0.97, 2.04 – 0.36, 1.00 0.99, 3.22 – – – – –
95% CI
Outpatient drug-free (n ⫽ 673)
0.59 0.26
0.21
– ⫺0.18 ⫺0.54 – – 0.25 0.36 0.21 ⫺0.31 – 0.39 – – 0.14 0.02 0.05
– – –
B
1.24*** – – – 1.80**** 1.30** – 0.83** 0.58**** – – 1.28*** 1.44**** 1.24*** 0.74*** – 1.48**** – – 1.15* 1.02* 1.01*
OR
Total (n ⫽ 3,793) 1.05, 1.44 – – – 1.54, 2.11 1.06, 1.63 – 0.73, 0.96 0.51, 0.67 – – 1.10, 1.50 1.23, 1.68 1.05, 1.44 0.60, 0.89 – 1.17, 1.87 – – 0.98, 1.35 1.00, 1.04 0.99, 1.11
95% CI
234 C.E. Grella et al. / Journal of Substance Abuse Treatment 19 (2000) 229–237
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3.3.5. Outpatient drug-free programs Individuals who were alcohol-dependent were more likely than those who were not to receive HIV-related services. IDUs were actually less likely than noninjectors to receive HIV-related services, as were employed individuals compared with unemployed. Individuals who were cocainedependent or who engaged in sex work were marginally less likely to receive these services.
4. Discussion This analysis demonstrated that HIV-related services are neither universally nor uniformly provided to individuals receiving drug treatment. A greater proportion of clients in residential and inpatient programs reported having received these services as compared with clients in outpatient methadone or drug-free treatment programs. With the exception of methadone treatment, HIV services were more often provided within group counseling settings than in individual counseling situations. The information provided was most frequently of a generalized nature regarding HIV/AIDS, rather than specifically addressing sex-risk, needle-risk, or health-care issues. Overall, men were more likely than women to receive HIV services. When examined by level of sex risk, high sex-risk men and women were more likely to report having received HIV-related services, although again there were modalityspecific differences. A smaller proportion of high sex-risk women in short-term inpatient and outpatient methadone treatment reported having received information on needlerisk reduction, sex-risk reduction, or health-care options for AIDS. The multivariate analyses indicated that, of the three components of high sex-risk behaviors examined, only individuals who engaged in sex work had a higher likelihood of receiving HIV-related services. Individuals who were at high risk of HIV infection by having either high-risk sexual partners or multiple sexual partners without consistently using condoms were no more likely to receive HIV-related services than other individuals. These findings suggest that some individuals who are at high sex risk may not be identified as such or, even if so identified, are not targeted to receive HIV-related services that would specifically address their risk behaviors. In particular, women in drug treatment who are at high sex-risk for HIV infection may remain unidentified and underserved. This finding is particularly noteworthy given the power differential inherent in the sexual relationships of many women drug users, particularly those who are economically dependent on their partners or whose drug use is intertwined with their sexual relationship (Amaro, 1995). Risk from having multiple sex partners or high-risk sex partners may be particularly difficult to ascertain, given the private nature of these behaviors. Staff in drug treatment programs may be reluctant to probe clients for information on their number and type of sexual partners. Additionally, staff may lack protocols that assist them in eliciting this information in a
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sensitive manner that reassures the client that such information will be kept confidential and that it is in the client’s interest to address their HIV sex-risk profile. Rather, HIV services seem to be directed on the basis of ethnicity (African Americans and Hispanics more than Whites) and social class (employed and insured less than unemployed and uninsured). Tentative support for this hypothesis comes from studies showing that the majority of women in treatment report that their counselors never addressed sexuality or sexual concerns in counseling sessions (Ladwig & Andersen, 1989; Wadsworth et al., 1995). Even in special sessions devoted solely to HIV-related issues, there are indications that the counseling is not delivered in a way that is tailored or personally relevant to clients. In an in-depth study of the HIV and AIDS counseling process using tape-recorded transcriptions of sessions and on-site observations, Kinnell and Maynard (1996) observed that even highly trained providers avoided directly discussing client’s specific sexual practices. Typically, counselors practiced information and advice-giving, did most of the talking, and tended to use hypothetical examples rather than attempting to tailor the sessions to clients’ specific situations. Clients tended to respond with silence and did not indicate that they found the material useful or personally relevant. The reluctance to discuss issues concerning sexuality, among both staff and clients, may be heightened when a woman has a history of sexual abuse or trauma. The finding that alcohol-dependent individuals were more likely than nondependent individuals to receive HIVrelated services is intriguing, given the evidence that alcohol use may be related to risky sexual behavior, although the evidence on this relationship is inconsistent (Dingle & Oei, 1997). Moreover, the finding that IDUs were no more likely than others to receive any type of HIV-related intervention, and even less likely to do so in outpatient drug-free treatment, provides evidence that individuals at risk for HIV through injection drug use are not being adequately targeted for risk-reduction interventions. Indeed, fewer than 40% of the individuals in methadone treatment programs reported receiving information on needle-risk reduction. Providing this information may pose a dilemma for treatment staff who believe abstinence is the ultimate treatment goal. Yet, since many methadone clients do continue some injection activity while in treatment, risk-reduction measures need to be incorporated within the broader treatment goals of drug use reduction and abstinence. Otherwise, although drug treatment provides an opportune moment for intervening with drug users at high risk for HIV, this opportunity is lost for the majority of individuals who enter drug treatment. Even though we found that the delivery of HIV-related services varied by type of drug treatment modality, gender, and sex-risk status, the programs themselves consistently reported that these services were provided to their clients. Data regarding service delivery within their programs is available from the administrators of approximately 70 (73%) of the programs included in the DATOS study. All of
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the administrators who responded to the survey except two stated that HIV prevention and education services were “not difficult” for their clients to obtain. In contrast, there was a wide variability among programs in each treatment modality in the percentages of clients who reported having received HIV risk-reduction services, ranging from nearly universal to none. Thus, the perceptions of program administrators that HIV education and prevention services are easily available within their programs stand in contrast to the reports of clients on whether they received risk-reduction services while in treatment. These findings highlight the need for programs to examine certain features of their treatment process in order to identify and remove potential barriers surrounding the provision of treatment and services to reduce HIV risk, particularly among those at greatest risk. It may be unrealistic for programs to expect that clients will feel free to disclose issues of a sexual nature until a bond of trust has been established with the counselor, which may require more than a few sessions to establish. Providers experienced in the provision of services in emotionally charged areas, such as sexuality, have suggested a “client-paced” approach (Wadsworth et al., 1995). Two-fifths of clients in this study reported that they had received HIV services from their primary counselor; approximately one fifth each received HIV services from a nurse or AIDS outreach worker. More research is needed to assess the impact of various staffing configurations, including client–staff matching based on gender and ethnicity, on delivering these services and reducing HIV-risk behaviors. In addition, both men and women may be reluctant to discuss issues related to sexuality in groups, especially mixed-gender groups. Because of managed care and the current cost-containment atmosphere, programs are now confronting forced decreases in length of stay and pressure to increase the use of groups as the preferred treatment delivery vehicle (Etheridge et al., 1997). An important area for future research is to determine the impact of these constraints on the client–counselor relationship, as well as other factors that may contribute to decreases in HIV-risk behaviors, such as services provided during treatment, client satisfaction, and treatment retention. Several limitations to this study must be noted. The data on receipt of HIV services are based on client self-report. Errors in recall of events occurring over 1 to 3 months of drug treatment are possible; even if individuals received HIV-related information they may not have recognized it as such. Some individuals may have selectively attended to this information in ways that are related to their risk status (e.g., higher-risk individuals may be more likely to have noticed and recalled receipt of HIV-related services). The findings from this study must also be interpreted within the context of the sampling procedure used in DATOS, which was a nonrandom selection of clients entering drug treatment programs. The study reported in this article is further limited by selective attrition of individuals between Intakes
1 and 2 and after 1 to 3 months in treatment, which limits the generalizability of the findings to individuals who are likely to remain in drug treatment for at least these lengths of time. Nevertheless, the study provides evidence that drug treatment programs have far to go in order to fully achieve their potential for reducing risk of HIV transmission/ infection among individuals in drug treatment.
Acknowledgments This work was supported by the National Institute on Drug Abuse (NIDA) grant no. U01- DA10378 as part of a Cooperative Agreement on the Drug Abuse Treatment Outcome Study (DATOS). The project includes a Coordinating DATOS Research Center (Robert L. Hubbard, Principal Investigator at NDRI) and two Collaborating Research Centers (M. Douglas Anglin, Principal Investigator at UCLA, and D. Dwayne Simpson, Principal Investigator at Texas Christian University) to conduct treatment evaluation studies in connection with NIDA (Bennett W. Fletcher, Principal Investigator at NIDA). Barry S. Brown chairs the DATOS Steering Committee. Dr. Anglin is also supported by NIDA Research Scientist Development Award (K02-DA00146). The interpretations and conclusions contained in this paper do not necessarily represent the positions of the other DATOS Research Centers, NIDA, or the Department of Health and Human Services. The authors wish to thank Elizabeth Teshome for her assistance with manuscript preparation. References Amaro, H. (1995). Love, sex, and power: considering women’s realities in HIV prevention. American Psychologist 50, 437–447. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. Anglin, M. D., Hser, Y. I., & Grella, C. E. (1997). Drug addiction and treatment careers among clients in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11, 308–323. Baker, A., Heather, N., Wodak, A., Dixon, J., & Holt, P. (1993). Evaluation of a cognitive-behavioral intervention for HIV prevention among injecting drug users. AIDS 7, 247–256. Ball, J. C., Lange, W. R., Myers, C. P., & Friedman, S. R. (1988). Reducing the risk of AIDS through methadone maintenance treatment. Journal of Health and Social Behavior 29, 214–226. Ball, J. C., & Ross, A. (1991). The Effectiveness of Methadone Maintenance Treatment: Patients, Programs, Services, and Outcome. New York: Springer-Verlag. Battjes, R. J., Pickens, R.W., & Brown, L. S. (1995). HIV infection and AIDS risk behaviors among injecting drug users entering mehadone treatment: an update. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 10, 90–96. Boatler, J., Knight, K., & Simpson, D. D. (1994). Assessment of an AIDS intervention program during drug abuse treatment. Journal of Substance Abuse Treatment 11, 367–372. Booth, R. E., Koester, S. K., & Pinto, F. (1995). Gender differences in sexrisk behaviors, economic livelihood, and self-concept among drug injectors and crack smokers. American Journal on Addictions 4, 313–322. Broome, K. M., Joe, G. W., & Simpson, D. D. (1999). HIV risk reduction in outpatient drug abuse treatment: individual and geographic differences. AIDS Education and Prevention 11, 293–306.
C.E. Grella et al. / Journal of Substance Abuse Treatment 19 (2000) 229–237 Brown, B. S. (1990–1991). AIDS and the provision of drug user treatment. International Journal of the Addictions 25, 1503–1514. Brown, B. S., & Beschner, G. M. (1989). AIDS and HIV infection: implications for drug abuse treatment. Journal of Drug Issues 19, 141–162. Brown, B. S., & Needle, R. H. (1994). Modifying the process of treatment to meet the threat of AIDS. International Journal of the Addictions 29, 1739–1752. Cole, S. C., & James, L. R. (1975). A revised treatment typology based on the DARP. American Journal of Drug and Alcohol Abuse 2, 37–49. D’Aunno, T., Vaughn, T. E., & McElroy, P. (1999). An institutional analysis of HIV prevention efforts by the nation’s outpatient drug abuse treatment units. Journal of Health and Social Behavior 40, 175–192. Dengelegi, L., Weber, J., & Torquato, S. (1990). Drug users’ AIDS-related knowledge, attitudes, and behaviors before and after AIDS education sessions. Public Health Report 105, 504–510. Dingle, G. A., & Oei, T. P. (1997). Is alcohol a cofactor of HIV and AIDS? Evidence from immunological and behavioral studies. Psychological Bulletin 122, 56–71. Etheridge, R. M., Hubbard, R. L., Anderson, J., Craddock, S. G., & Flynn, P. M. (1997). Treatment structure and program services in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11, 244–260. Fletcher, B. W., Tims, F. M., & Brown, B. S. (1997). Drug Abuse Treatment Outcome Study (DATOS): treatment evaluation research in the United States. Psychology of Addictive Behaviors 11, 216–229. Flynn, P. M., Craddock, S. G., Hubbard, R. L., Anderson, J., & Etheridge, R. M. (1997). Methodological overview and research design for the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11, 230–243. Hartel, D. (1994). Context of HIV risk behavior among female injecting drug users and female sexual partners of injecting drug users. In R. J. Battjes, Z. Sloboda, & W. C. Grace (Eds.), The Context of HIV Risk Among Drug Users and Their Sexual Partners (pp. 41–47). NIDA Research Monograph no. 143. NIH Publication No. 94-3750. Rockville, MD: National Institute on Drug Abuse. Kinnell, A. M. K., & Maynard, D. W. (1996). The delivery and receipt of safer sex advice in pretest counseling sessions for HIV and AIDS. Journal of Contemporary Ethnography 24, 405–437. Ladwig, G. B., & Andersen, M. D. (1989). Substance abuse in women: relation-
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ship between chemical dependency of women and past reports of physical and/or sexual abuse. International Journal of the Addictions 24, 739–754. Malow, R. M., & Ireland, S. J. (1996). HIV risk correlates among noninjection cocaine dependent men in treatment. AIDS Education and Prevention 8, 226–235. Metzger, D. S., Woody, G. E., McLellan, A. T., O’Brien, C. P., Druley, P., Navaline, H., DePhilippis, D., Stolley, P., & Abrutyn, E. (1993). Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of treatment: an 18-month prospective follow-up. Journal of Acquired Immune Deficiency Syndromes 6, 1049–1056. Norušis, M. J. (1992). SPSS Professional Statistics, Release 5. Chicago: SPSS. Saxon, A. J., & Calsyn, D. A. (1992). Comparison of HIV-associated risk behaviors of primary intravenous stimulant users and opioid-addicted subjects on methadone maintenance. American Journal on Addictions 1, 304–314. Shoptaw, S., Frosch, D., Rawson, R. A., & Ling, W. (1997). Cocaine abuse counseling as HIV prevention. AIDS Education and Prevention 9, 15–24. Shoptaw, S., Reback, C. J., Frosch, D., & Rawson, R. A. (1998). Stimulant abuse treatment as HIV prevention. Journal of Addictive Diseases 17(4), 19–32. Sorensen, J. L., London, J., Heitzmann, C., Gibson, D. R., Morales, E. S., Dumontet, R., & Acree, M. (1994). Psychoeducation group approach: HIV risk reduction in drug users. AIDS Education and Prevention 6, 95–112. Sorensen, J. L., & Miller, M. S. (1996). Impact of HIV risk and infection on delivery of psychosocial treatment services in outpatient programs. Journal of Substance Abuse Treatment 13, 387–395. Wadsworth, R., Spampneto, A. M., & Halbrook, B. M. (1995). The role of sexual trauma in the treatment of chemically dependent women: addressing the relapse issue. Journal of Counseling and Development 73, 401–406. Watters, J. K. (1996). Impact of HIV risk and infection and the role of preventive services. Journal of Substance Abuse Treatment 13, 375–385. Wayment, H. A., Newcomb, M. D., & Hannemann, V. L. (1993). Female and male intravenous drug users not-in-treatment: are they at differential risk for AIDS? Sex Roles 28, 111–124. Wells, D. V. B., & Jackson, J. F. (1992). HIV and chemically dependent women: recommendations for appropriate health care and drug treatment services. International Journal of the Addictions 27, 571–585.
Article
Delivery of HIV risk-reduction services in drug treatment programs Christine E. Grella, Ph.D.a,*, Rose M. Etheridge, Ph.D.b, Vandana Joshi, Ph.D.a, M. Douglas Anglin, Ph.D.a a
Drug Abuse Research Center, Neuropsychiatric Institute, University of California, Los Angeles, 1640 S. Sepulveda Boulevard, Suite 200, Los Angeles, CA 90025, USA b National Development and Research Institutes, Inc., Raleigh, NC, USA Received 9 July 1999; accepted 10 November 1999
Abstract This study examined services received for HIV risk reduction among individuals in drug treatment. Analyses were conducted using data from 4,412 participants in the national Drug Abuse Treatment Outcome Study (DATOS), a prospective multisite study of drug treatment effectiveness. A higher percentage of individuals in long-term residential programs received HIV-related services, compared with clients in short-term inpatient, methadone maintenance, and outpatient drug-free programs. More men than women, and individuals at higher sex-risk as compared with those at lower sex-risk, received HIV services. Logistic regression analyses indicated that individuals who engaged in sex work had a higher likelihood than those who did not, of receiving HIV-related services, although individuals with high-risk or multiple sexual partners were no more likely than others to receive HIV services. More comprehensive service delivery is needed in order to reduce the risk for HIV among clients in drug treatment. © 2000 Elsevier Science Inc. All rights reserved. Keywords: HIV services; HIV risk reduction; Treatment modality; Gender; Sex risk
1. Introduction The transmission of HIV among drug users has dramatically enlarged the scope of drug treatment in order to address the risk of HIV among individuals in treatment (Brown, 1990–91; Brown & Beschner, 1989; Brown & Needle, 1994; Sorensen & Miller, 1996; Watters, 1996). Treatment providers now offer a wider range of services that encompass HIV education and prevention interventions, such as HIV testing and counseling, general education regarding HIV, and promotion of risk-reduction practices. One study showed that outpatient substance abuse treatment units significantly increased their HIV prevention efforts, particularly in regard to injection drug users, from 1988 to 1995 (D’Aunno et al., 1999). Prior research has demonstrated that drug treatment is associated with increases in HIV-related knowledge (Malow & Ireland, 1996; Sorensen et al., 1994) and reductions in drug use and high-risk injection behaviors (Baker et al., 1993; Ball & Ross, 1991; Ball et al., 1988; Boatler et al., 1994; Broome et al., 1999; Dengelegi et al., 1990; Metzger et al., 1993; Saxon & Calsyn, 1992), especially among opiate users
* Corresponding author. Tel.: 310-445-0874, x243; fax: 310-473-7885. E-mail address: [email protected] (C.E. Grella).
in methadone maintenance treatment. Stimulant users have been shown to increase safer sex practices subsequent to participation in drug treatment (Shoptaw et al., 1997, 1998), although high-risk sexual behaviors have been more resistant to change among drug users (Battjes et al., 1995). The delivery of drug treatment services varies across types of drug treatment programs. Historically, drug treatment programs have been categorized according to type of treatment modality (Cole & James, 1975; Etheridge et al., 1997); for example, pharmacotherapeutic approaches, such as methadone maintenance treatment for opiate addiction, have been distinguished from outpatient drug-free treatment. Similarly, therapeutic communities, which are longterm community-based residential programs, have been differentiated from hospital-based inpatient programs, which typically provide treatment for less than 30 days, often limited to detoxification. Not only do the types of individuals entering into these different kinds of drug treatment programs vary in terms of their drug use history and severity, their prior treatment history, and other individual characteristics (Anglin et al., 1997), but treatment intensity, expected duration, and process typically differ across the treatment modalities (Etheridge et al., 1997). It is important, then, to distinguish among these types of treatment modalities when examining the delivery of HIV risk-reduction services within drug treatment programs.
0740-5472/00/$ – see front matter © 2000 Elsevier Science Inc. All rights reserved. PII: S0740-5472(00)00 1 0 2 - 1
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Furthermore, the delivery of HIV services within programs may be influenced by the characteristics of individuals entering into drug treatment. Although the risk for HIV is likely to vary by gender, it is unclear whether treatment programs are tailoring HIV risk-reduction interventions to address the specific needs of men and women drug users. Women drug users may be differentially at risk for HIV infection, compared with men, because of the nature of their drug use and sexual behavior (Amaro, 1995; Hartel, 1994; Wells & Jackson, 1992). Women injection drug users (IDUs) are more likely than men to share injection equipment with others, particularly their spouse or sexual partners, and to be affected by others’ needle-cleaning practices (Wayment et al., 1993). Moreover, women IDUs are more likely than men to have sexual relations with other IDUs and to exchange sex for money or drugs (Booth et al., 1995). Yet to be determined is whether HIV risk-reduction interventions as typically provided reach those individuals who are most at risk for HIV infection. In particular, individuals who engage in high-risk sexual behaviors may not be adequately assessed or targeted for HIV risk-reduction services when they enter drug treatment. Since the sexual behaviors that put individuals at risk for HIV infection are either stigmatized (e.g., men who have sex with men), illegal (e.g., sex work), or considered to be private issues concerning one’s personal relationships (e.g., number and type of sexual partners, use of condoms), individuals who enter drug treatment may fail to self-disclose these high-risk sex behaviors and program staff may neglect to question them or to probe for more detail. Concerns about confidentiality and privacy, which are heightened with regard to HIV, may prevent staff from identifying high-risk individuals who would benefit from HIV risk-reduction interventions. The goal of this study was to evaluate the extent of services received for HIV risk reduction among clients in drug treatment across four different types of treatment modalities, to examine gender differences in HIV services received, and to determine whether individuals who are at higher sex-related risk for HIV are more likely than others to receive HIV services. Analyses were conducted using the national Drug Abuse Treatment Outcome Study (DATOS), a prospective multisite study of drug treatment effectiveness sponsored by the National Institute on Drug Abuse.
2. Method
patient drug-free programs (ODF) (see Flynn et al., 1997 for a description of the DATOS methodology). The intake assessment consisted of two 90-minute interviews: Intake 1 was administered at admission to treatment or shortly thereafter, and Intake 2 was completed after about 7 days of treatment. Intake 1 primarily obtained baseline data on background characteristics; Intake 2 provided information for clinical assessment. Interviews were conducted with clients after 1 and 3 months in treatment or aftercare about the services they had received. 2.2. Subjects Subjects for the study reported in this paper included 2,911 men and 1,501 women who completed both Intakes 1 and 2 and an in-treatment interview at either 3 months (LTR, ODF, and OMT) or 1 month (STI). We used a listwise deletion of cases who were missing data on any of the variables used in the analyses, which are described below. Among the subjects included for analysis in this study, two thirds (66%) were male and the overall mean age was 32.6 years (SD ⫽ 7.6). The gender and age distributions within modalities were similar to the overall sample, except that clients in OMT were older with a mean age of 37 years (SD ⫽ 7.4). About two fifths (44%) were African American, 41% were White, 13% were Hispanic, and the remainder (2%) were either Asian or “other.” Ethnic distributions within modalities were proportionately similar, with the exception of OMT, where more of the clients were White and fewer were African American. The sample consisted mainly of high school graduates (39%) and individuals with 9–12 years of school (35%). About one half of the sample was employed during the 12 months prior to admission to the DATOS treatment episode. Only 31% were presently married or living with a partner. The majority of the clients at intake (52%) reported cocaine as their primary problem drug and approximately one fifth (19%) reported heroin. Primary problem drug varied by modality, with 80% of the clients in OMT reporting heroin as their primary drug problem. In contrast, about two thirds of the clients in LTR and STI programs and one half of the clients in ODF programs reported cocaine as their primary problem drug. Approximately, two fifths of the sample was dependent on alcohol. DATOS was the first drug treatment episode for about half of the sample. Additionally, one third had antisocial personality disorder and 12% had a lifetime diagnosis of major depressive disorder.
2.1. DATOS data collection DATOS is a comprehensive multisite prospective study of drug treatment effectiveness (Fletcher et al., 1997). A population of 10,010 DATOS clients has been interviewed at entry to treatment in a sample of 96 programs within the United States from 1991 to 1993. Clients were selected from four drug treatment modalities: 3,122 clients from 14 short-term inpatient programs (STI), 2,774 clients from 21 long-term residential programs (LTR), 1,540 clients from 29 outpatient methadone treatment programs (OMT), and 2,574 clients from 32 out-
2.3. Variables Variables were chosen for the analysis in order to test the hypothesis that individuals who engage in high-risk sexual behaviors would be more likely to receive HIV services in drug treatment programs, while controlling for other relevant subject characteristics, including gender. The construction and coding of the variables used in this analysis are summarized below. All dichotomous variables were coded with 1 ⫽ yes and 0 ⫽ no, unless indicated.
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231
2.3.1. Demographic/background characteristics This domain included variables for gender, age, ethnicity (dummy variables for African American, Latino, and “other,” with White as the reference category), educational status (high school degree ⫽ 0, college degree ⫽ 1, with less than a high school degree as the reference category), and marital status (currently married or living as married ⫽ 1, not married ⫽ 0). Full-time work referred to employment in the year prior to treatment (employed ⫽ 1, unemployed ⫽ 0). A dichotomous variable measured whether treatment in the DATOS episode was covered partially or in full by health insurance.
2.3.9. HIV services Receipt of HIV-related services was based on self-report. Clients were asked whether they had received any type of HIV-related service while in treatment and, if so, the type of service received (i.e., needle-risk reduction, sex-risk reduction, health-care options for HIV/AIDS, and general information on HIV/AIDS); whether HIV risk reduction was identified as a treatment goal; and whether issues regarding HIV risk were discussed in individual counseling or group sessions.
2.3.2. Drug and alcohol dependence Separate dichotomous variables measured dependence on heroin, cocaine, and alcohol. Dependence was defined as meeting criteria from the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIII-R; American Psychiatric Association, 1987) for lifetime dependence. In addition, a dichotomous variable indicated whether the individual had injected drugs in the year prior to entering treatment.
First, differences in receipt of HIV services by type of DATOS treatment modality, gender, and sex-risk status were examined using chi-square analyses. Next, separate logistic regression models were constructed for the total sample and for each of the four modalities to examine whether individuals who engaged in high-risk sexual behavior were more likely to receive any type of HIV-related services, controlling for other subject characteristics. All analyses were conducted using SPSS (Norušis, 1992).
2.3.3. Prior drug treatment This variable indicated whether or not the client had ever received treatment for a drug problem prior to entering DATOS.
3. Results
2.3.4. HIV test Subjects were asked whether or not they had ever been tested for HIV, however, they were not asked to report test results. 2.3.5. Illegal activity Individuals were asked how many illegal activities they had engaged in within the prior 12 months prior to treatment entry; the sum was reported as a continuous variable. 2.3.6. Psychiatric status Three separate variables indicated whether individuals met the DSM-III-R criteria for a diagnosis of antisocial personality disorder, general anxiety disorder, or major depressive disorder. 2.3.7. Sex risk Sex risk was measured by three dichotomous variables: whether they had exchanged sex for money or drugs in the 12 months prior to entering treatment; whether they had a high-risk sex partner (defined as a sex partner who was HIVpositive, a man who has sex with men, a sex worker, or an injection drug user); and whether they reported having had two or more sex partners in the previous 12 months without always using a condom. A dichotomous composite sex-risk variable was constructed combining responses to these items, with a positive response on any of the three items coded as 1 (high risk), and others coded as 0 (low risk). 2.3.8. Modality The DATOS treatment modality was indicated by three dichotomous variables, one each for LTR, STI, and OMT, with ODF as the reference category.
2.4. Statistical analysis
3.1. HIV-related services received by clients by drug treatment modality and gender Overall, 17% of the clients reported that HIV risk reduction was identified as a treatment goal, 33% discussed HIV risk in individual counseling sessions, and 44% discussed HIV risk in group sessions. Table 1 provides information on the HIV services received by modality. LTR programs had the highest proportion of clients (86%) who received an HIV-related service during the first 3 months of treatment, 2(3) ⫽ 548.8, p ⬍ .001. A majority (60%) of the clients in STI programs reported receiving HIV services during 1 month of treatment, although fewer than half of the clients in OMT and ODF reported receiving an HIV-related service during the first 3 months of treatment. Approximately twice as many individuals in LTR and OMT reported that HIV risk reduction was identified as a goal in their treatment plan as compared with individuals in STI and ODF, 2(3) ⫽ 99.4, p ⬍ .001. Over half of the clients in OMT reported that HIV risk was discussed in individual counseling sessions, compared with about one third or fewer of the clients in the other modalities, 2(3) ⫽ 282.8, p ⬍ .001. Conversely, fewer clients in OMT reported discussing HIV risk in group sessions, which was more commonly reported by clients in the other modalities, 2(3) ⫽ 77.5, p ⬍ .001. When examined by type of HIV-related service received, clients in all modalities most often reported having received general knowledge about HIV; they less frequently reported receiving information on needle-risk reduction, sex-risk reduction, or health-care options for HIV/AIDS. Over half of the clients in LTR treatment reported receiving information on needle-risk reduction, as compared with approximately 30–
43.0 49.8 38.6 91.7 42.0 47.1 36.4 90.9 43.5 51.1 39.7 92.1 42.4 52.0 30.4 91.7 41.7 50.0 30.8 91.7 42.8 52.9 30.2 91.8 37.7 38.2 29.2 88.0 29.3** 29.9** 25.6 89.0 43.8 44.3 31.9 87.2 30.9 41.0 19.0 91.8 34.7 43.1 16.0 90.5 Gender differences significant at * p ⭐ .05, **p ⭐ .01. All differences by modality for the total sample are significant at p ⭐ .05. b
55.0 58.6 61.5 91.9 55.1 61.2 60.5 93.6
55.0 60.4 60.8 93.1
60.6 17.3 33.5 43.9 (N ⫽ 2,642) 57.8** 16.4 34.0 42.6 (n ⫽ 855) 62.1 17.8 33.3 44.6 (n ⫽ 1,787) 44.0 11.1 34.2 48.7 (N ⫽ 375) 40.3 9.7 32.3 45.3 (n ⫽ 120) 46.0 11.9 35.1 50.5 (n ⫽ 255) 43.3 21.0 53.6 31.6 (N ⫽ 390) 45.3 19.8 50.5 35.2 (n ⫽ 164) 41.9 21.9 55.7 29.2 (n ⫽ 226) 60.0 12.4 19.9 48.8 (N ⫽ 836) 58.1 10.7 19.0 43.7* (n ⫽ 262) 60.4 13.3 20.4 51.3 (n ⫽ 574) 83.4 25.3 37.5 46.2 (n ⫽ 309) 87.3 24.1 32.4 43.2 (n ⫽ 732)
86.1 24.5 34.0 44.1 (N ⫽ 1,041)
29.1 40.1 20.4 92.3 a
Services
Short-term inpatient
Table 1 HIV services received by gendera and type of treatment modalityb (%)
High-risk sexual activity was compared for men and women. A larger proportion of women reported having exchanged sex for drugs or money in the 12 months prior to treatment entry (30% vs. 6%), 2(1) ⫽ 448, p ⬍ .001, but about equal proportions of men and women reported having a high-risk sexual partner (approximately 30%) or having two or more sexual partners without always using a condom (approximately 40%). The composite measure of high-risk sexual status indicated that 50.7% of men and 55.1% of women were classified as having high sex-risk for HIV. Data on the receipt of HIV-related services by gender, sex-risk status, and modality are summarized in Table 2. Information on high-risk men is presented in the upper part of the table. Across all modalities, a larger proportion of high sex-risk as compared with low sex-risk men received HIVrelated services (66% vs. 58%), 2(1) ⫽ 20.5, p ⫽.001. More high sex-risk men also had HIV risk reduction specified as a treatment goal (19% vs. 16%), 2(1) ⫽ 5.3, p ⬍ .05, and discussed HIV risk within group sessions (47% vs. 42%), 2(1) ⫽ 8.7, p ⬍ .01. Among men who received HIV services in STI, fewer high sex-risk men received information on needle-risk reduction (25% vs. 33%), 2(1) ⫽ 4.3, p ⬍ .05, and health-care options (16% vs. 26%), 2(1) ⫽ 8.6, p ⬍ .01. Information regarding receipt of HIV services by women of high and low sex-risk status is shown in the lower half of Table 2. Across all modalities, a greater proportion of high sex-risk women received HIV services (62% vs. 52%), 2(1) ⫽ 15.3, p ⫽.001, and discussed HIV risk within group sessions (45% vs. 40%), 2(1) ⫽ 3.8, p ⫽.05. Among women who received HIV services in STI, a smaller proportion of high sex-risk women received information on needle-risk reduction (29% vs. 43%), 2(1) ⫽ 5.6, p ⬍ .05, sex-risk reduction (37% vs. 50%), 2(1) ⫽ 4.2, p ⬍ .05, and health-care options (12% vs. 22%), 2(1) ⫽ 5.0, p ⬍ .05. Among women in OMT who received HIV services, fewer high sex-risk women received information on needle-risk reduction (22% vs. 38%), 2(1) ⫽ 4.9, p ⬍
Outpatient methadone
3.2. HIV services received by gender, sex-risk status, and drug treatment modality
Received HIV-related services Risk reduction from AIDS as a goal in treatment plan Discussed risk of HIV infection in individual sessions Discussed risk of HIV infection in group sessions Among those who received any service: Type of HIV services received Reduce needle risk Reduce risk of sex transmission Health-care options for AIDS General knowledge about HIV
Outpatient drug-free
Total
40% of the clients in the other three modalities, 2(3) ⫽ 116.4, p ⬍ .001. About one half of the clients who received HIV services said that they received information on sexual risk reduction, with LTR having the largest (60%) and OMT the fewest (38%) number of clients who received this information, 2(3) ⫽ 94.4, p ⬍ .001. Twice as many clients in LTR treatment as those in the other modalities reported receiving information on health-care options for HIV/AIDS, 2(3) ⫽ 376.9, p ⬍ .001. Information on gender differences in HIV services received is also shown in Table 1. Overall, a higher proportion of men than women reported receiving HIV-related services (62% vs. 58%), 2(1) ⫽ 7.5, p ⬍ .01. In addition, in OMT more men received information on needle-risk reduction (44% vs. 29%), 2(1) ⫽ 8.6, p ⬍ .01, and on sexual transmission (44% vs. 30%), 2(1) ⫽ 8.3, p ⬍ .01.
Men Women Total Men Women Total Men Women Total Men Women Total Men Women Total (n ⫽ 855) (n ⫽ 379) (N ⫽ 1,234) (n ⫽ 957) (n ⫽ 458) (N ⫽ 1,415) (n ⫽ 544) (n ⫽ 364) (N ⫽ 908) (n ⫽ 555) (n ⫽ 300) (N ⫽ 855) (n ⫽ 2,911) (n ⫽ 1,501) (N ⫽ 4,412)
C.E. Grella et al. / Journal of Substance Abuse Treatment 19 (2000) 229–237
Long-term residential
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233
Table 2 HIV services received by gender, risk status and type of modality (%) Long-term residential Short-term inpatient
Outpatient methadone Outpatient drug-free
Total
Services
High risk
High risk
High risk
Men Received HIV-related services Risk reduction from AIDS as a goal in treatment plan Discussed risk of HIV infection in individual sessions Discussed risk of HIV infection in group sessions Among those who received any service: Type of HIV services received Reduce needle risk Reduce risk of sex transmission Health care options for AIDS General knowledge about HIV Women Received HIV-related services Risk reduction from AIDS as a goal in treatment plan Discussed risk of HIV infection in individual sessions Discussed risk of HIV infection in group sessions Among those who received any service: Type of HIV services received Reduce needle risk Reduce risk of sex transmission Health care options for AIDS General knowledge about HIV
(n ⫽ 502) (n ⫽ 353) (n ⫽ 486) (n ⫽ 471) (n ⫽ 251) (n ⫽ 293) (n ⫽ 241) (n ⫽ 314) (n ⫽ 1,480) (n ⫽ 1,431) 89.2 84.4* 61.9 58.8 44.2 39.9 49.0 43.6 66.1 57.9*** 24.1
Low risk
24.1
High risk
16.1
Low risk
10.4**
25.5
Low risk
18.8
High risk
10.0
Low risk
13.4
19.4
Low risk
16.1*
31.9 34.8 27.2 15.3*** 58.6 53.6 32.8 37.9 35.0 44.6 41.1 53.7 48.8 36.3 23.2*** 51.5 50.0 47.3 (n ⫽ 443) (n ⫽ 289) (n ⫽ 300) (n ⫽ 274) (n ⫽ 111) (n ⫽ 115) (n ⫽ 118) (n ⫽ 137) (n ⫽ 972)
32.9 41.9** (n ⫽ 815)
56.9 63.0 60.7 93.7 (n ⫽ 263) 84.0
52.3 58.5 60.2 93.4 (n ⫽ 116) 81.9
43.7 51.0 39.0 92.9 (n ⫽ 828) 62.3
43.3 51.2 40.5 91.2 (n ⫽ 673) 52.3***
25.9
24.1
17.0
15.6
25.3 37.0 15.7 93.7 (n ⫽ 237) 62.9 9.3
33.2* 43.4 25.6** 91.0 (n ⫽ 221) 52.9*
40.5 40.5 26.1 90.1 (n ⫽ 199) 43.7
47.0 47.8 37.4 84.4 (n ⫽ 165) 47.3
44.1 51.8 28.8 90.7 (n ⫽ 129) 45.7
12.2
17.6
22.4
12.4
41.6 54.0 31.4 92.7 (n ⫽ 171) 36.3 7.6
41.4 31.0 44.9 49.1 (n ⫽ 217) (n ⫽ 92)
22.8 16.3 48.7 47.3 39.8 40.7 (n ⫽ 147) (n ⫽ 115) (n ⫽ 87)
53.3 28.5* (n ⫽ 77)
29.5 46.5 (n ⫽ 58)
34.5 44.4 (n ⫽ 62)
36.0 44.8 (n ⫽ 509)
32.5 39.8* (n ⫽ 346)
56.2 58.1 58.5 91.2
28.6 37.4 11.6 91.2
37.7* 37.7* 39.0*** 88.3
51.7 55.2 36.2 91.4
32.3* 45.2 25.8 91.9
41.8 45.8 34.8 91.0
42.2 49.1 38.7 90.8
52.2 59.8 68.5 93.5
42.6* 50.4* 21.7* 89.6
21.8 23.0 13.8 89.7
*p ⭐ .05, **p ⭐ .01, *** p ⭐ .001
.05, sex-risk reduction (23% vs. 38%), 2(1) ⫽ 4.2, p ⬍ .05, and health-care options for AIDS (14% vs. 39%), 2(1) ⫽ 13.6, p ⫽ .001. Among women in ODF who received HIV services, more high sex-risk women received information on needle-risk reduction (52% vs. 32%), 2(1) ⫽ 4.7, p ⬍ .05. 3.3. Logistic regression models for HIV services received by drug treatment modality In order to determine which subject characteristics, including high-risk sexual behaviors, increased the likelihood of receiving HIV-related services, separate logistic regression models were constructed for the total sample and for each modality. Each of the three sex-risk variables (i.e., having two or more sex partners without always using condoms, having a high-risk sex partner, engaging in sex work) was entered separately into the models to test whether they were differentially related to the receipt of services. These data are summarized in Table 3. 3.3.1. Total sample Men were 24% more likely than women to receive HIV services. African Americans and Hispanics were more likely than Whites to receive HIV-related services. Individuals who were employed or who had health insurance were less likely than unemployed or uninsured individuals, respectively, to receive HIV-related services. Individuals diagnosed with antisocial personality disorder, alcohol dependence, or cocaine dependence were more likely than their respective comparison groups to receive HIV-related services, however, those diagnosed with heroin dependence
were less likely. Individuals who engaged in sex work were approximately 50% more likely to receive HIV-related services, although individuals with high-risk or multiple sex partners were no more likely than others to receive these services. Individuals who had a prior HIV test, had prior drug treatment, or who had engaged in more illegal acts were all marginally more likely to receive HIV services. 3.3.2. Long-term residential programs African Americans and Hispanics were more likely than Whites to receive HIV-related services in this modality. Individuals who were unemployed, did not have health insurance, or had major depressive disorder were marginally more likely to receive HIV-related services. 3.3.3. Short-term inpatient programs African Americans and individuals of “other” ethnic groups were more likely than Whites to receive HIV services, as were individuals who had a diagnosis of major depressive disorder, were alcohol-dependent, engaged in sex work, or had taken a prior HIV test. Individuals with generalized anxiety disorder were marginally less likely to receive HIV-related services. 3.3.4. Outpatient methadone treatment programs African Americans and Hispanics were more likely than Whites to receive HIV-related services and individuals who were employed were less likely than unemployed individuals. Individuals with antisocial personality disorder were marginally more likely to receive these services.
– – – –
Male Married Age Education Level African American (referent ⫽ White) Hispanic (referent ⫽ White) Other ethnic group (referent ⫽ White) Full-time employed Has health insurance Major depressive disorder General anxiety disorder Antisocial personality disorder Alcohol-dependent Cocaine-dependent Heroin-dependent Injection drug use Sex work High-risk sex partner Multiple sex partners without condom use HIV test Prior drug treatment Number illegal acts 0.77 0.69
– – – – 2.16**** 1.99** – 1.39* 0.70* 1.73* – – – – – – – – – – – –
OR – – – – 1.40, 3.32 1.18, 3.37 – 0.97, 2.04 0.48, 1.04 0.91, 3.18 – – – – – – – – – – – –
95% CI
0.48 0.87 – ⫺0.40 0.38 ⫺0.55 – 0.25 – – – 0.45 – – 0.46 – –
–
– – – –
B – – – – 1.62**** – 2.39** – 0.67*** 1.46** 0.58* – 1.29** – – – 1.57** – – 1.58**** – –
OR
Short-term inpatient (n ⫽ 1,217) – – – – 1.19, 2.06 – 1.05, 5.44 – 0.52, 0.90 1.01, 2.12 0.31, 1.02 – 1.00, 1.66 – – – 1.06, 2.32 – – 1.23, 2.04 – –
95% CI
0.87 0.44 – ⫺0.74 – – – 0.31 – – – – – – – – – –
– – – –
B – – – – 2.39**** 1.56** – 0.48**** – – – 1.37* – – – – – – – – – –
OR – – – – 1.63, 3.43 1.01, 2.30 – 0.34, 0.69 – – – 1.00, 1.87 – – – – – – – – – –
95% CI
Outpatient methadone (n ⫽ 820)
Note: B ⫽ regression coefficient; OR ⫽ odds ratio; CI ⫽ confidence interval; – Indicates variable was nonsignificant in the model. *p ⬍ .10, **p ⭐ .05, ***p ⬍ .01, ****p ⬍ .001.
0.33 ⫺0.36 0.55 – – – – – – – – – – – –
–
B
Variable
Long-term residential (n ⫽ 1,083)
Table 3 Logistic regressions predicting receipt of HIV services by drug treatment modality
0.49 – – – – – – ⫺0.55 – – – – 0.40 0.35 – ⫺0.50 0.56 – – – – –
B 1.62** – – – – – – 0.58*** – – – – 1.49** 1.43* – 0.61** 1.75* – – – – –
OR
1.09, 2.39 – – – – – – 0.40, 0.77 – – – – 1.04, 2.10 0.97, 2.04 – 0.36, 1.00 0.99, 3.22 – – – – –
95% CI
Outpatient drug-free (n ⫽ 673)
0.59 0.26
0.21
– ⫺0.18 ⫺0.54 – – 0.25 0.36 0.21 ⫺0.31 – 0.39 – – 0.14 0.02 0.05
– – –
B
1.24*** – – – 1.80**** 1.30** – 0.83** 0.58**** – – 1.28*** 1.44**** 1.24*** 0.74*** – 1.48**** – – 1.15* 1.02* 1.01*
OR
Total (n ⫽ 3,793) 1.05, 1.44 – – – 1.54, 2.11 1.06, 1.63 – 0.73, 0.96 0.51, 0.67 – – 1.10, 1.50 1.23, 1.68 1.05, 1.44 0.60, 0.89 – 1.17, 1.87 – – 0.98, 1.35 1.00, 1.04 0.99, 1.11
95% CI
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3.3.5. Outpatient drug-free programs Individuals who were alcohol-dependent were more likely than those who were not to receive HIV-related services. IDUs were actually less likely than noninjectors to receive HIV-related services, as were employed individuals compared with unemployed. Individuals who were cocainedependent or who engaged in sex work were marginally less likely to receive these services.
4. Discussion This analysis demonstrated that HIV-related services are neither universally nor uniformly provided to individuals receiving drug treatment. A greater proportion of clients in residential and inpatient programs reported having received these services as compared with clients in outpatient methadone or drug-free treatment programs. With the exception of methadone treatment, HIV services were more often provided within group counseling settings than in individual counseling situations. The information provided was most frequently of a generalized nature regarding HIV/AIDS, rather than specifically addressing sex-risk, needle-risk, or health-care issues. Overall, men were more likely than women to receive HIV services. When examined by level of sex risk, high sex-risk men and women were more likely to report having received HIV-related services, although again there were modalityspecific differences. A smaller proportion of high sex-risk women in short-term inpatient and outpatient methadone treatment reported having received information on needlerisk reduction, sex-risk reduction, or health-care options for AIDS. The multivariate analyses indicated that, of the three components of high sex-risk behaviors examined, only individuals who engaged in sex work had a higher likelihood of receiving HIV-related services. Individuals who were at high risk of HIV infection by having either high-risk sexual partners or multiple sexual partners without consistently using condoms were no more likely to receive HIV-related services than other individuals. These findings suggest that some individuals who are at high sex risk may not be identified as such or, even if so identified, are not targeted to receive HIV-related services that would specifically address their risk behaviors. In particular, women in drug treatment who are at high sex-risk for HIV infection may remain unidentified and underserved. This finding is particularly noteworthy given the power differential inherent in the sexual relationships of many women drug users, particularly those who are economically dependent on their partners or whose drug use is intertwined with their sexual relationship (Amaro, 1995). Risk from having multiple sex partners or high-risk sex partners may be particularly difficult to ascertain, given the private nature of these behaviors. Staff in drug treatment programs may be reluctant to probe clients for information on their number and type of sexual partners. Additionally, staff may lack protocols that assist them in eliciting this information in a
235
sensitive manner that reassures the client that such information will be kept confidential and that it is in the client’s interest to address their HIV sex-risk profile. Rather, HIV services seem to be directed on the basis of ethnicity (African Americans and Hispanics more than Whites) and social class (employed and insured less than unemployed and uninsured). Tentative support for this hypothesis comes from studies showing that the majority of women in treatment report that their counselors never addressed sexuality or sexual concerns in counseling sessions (Ladwig & Andersen, 1989; Wadsworth et al., 1995). Even in special sessions devoted solely to HIV-related issues, there are indications that the counseling is not delivered in a way that is tailored or personally relevant to clients. In an in-depth study of the HIV and AIDS counseling process using tape-recorded transcriptions of sessions and on-site observations, Kinnell and Maynard (1996) observed that even highly trained providers avoided directly discussing client’s specific sexual practices. Typically, counselors practiced information and advice-giving, did most of the talking, and tended to use hypothetical examples rather than attempting to tailor the sessions to clients’ specific situations. Clients tended to respond with silence and did not indicate that they found the material useful or personally relevant. The reluctance to discuss issues concerning sexuality, among both staff and clients, may be heightened when a woman has a history of sexual abuse or trauma. The finding that alcohol-dependent individuals were more likely than nondependent individuals to receive HIVrelated services is intriguing, given the evidence that alcohol use may be related to risky sexual behavior, although the evidence on this relationship is inconsistent (Dingle & Oei, 1997). Moreover, the finding that IDUs were no more likely than others to receive any type of HIV-related intervention, and even less likely to do so in outpatient drug-free treatment, provides evidence that individuals at risk for HIV through injection drug use are not being adequately targeted for risk-reduction interventions. Indeed, fewer than 40% of the individuals in methadone treatment programs reported receiving information on needle-risk reduction. Providing this information may pose a dilemma for treatment staff who believe abstinence is the ultimate treatment goal. Yet, since many methadone clients do continue some injection activity while in treatment, risk-reduction measures need to be incorporated within the broader treatment goals of drug use reduction and abstinence. Otherwise, although drug treatment provides an opportune moment for intervening with drug users at high risk for HIV, this opportunity is lost for the majority of individuals who enter drug treatment. Even though we found that the delivery of HIV-related services varied by type of drug treatment modality, gender, and sex-risk status, the programs themselves consistently reported that these services were provided to their clients. Data regarding service delivery within their programs is available from the administrators of approximately 70 (73%) of the programs included in the DATOS study. All of
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the administrators who responded to the survey except two stated that HIV prevention and education services were “not difficult” for their clients to obtain. In contrast, there was a wide variability among programs in each treatment modality in the percentages of clients who reported having received HIV risk-reduction services, ranging from nearly universal to none. Thus, the perceptions of program administrators that HIV education and prevention services are easily available within their programs stand in contrast to the reports of clients on whether they received risk-reduction services while in treatment. These findings highlight the need for programs to examine certain features of their treatment process in order to identify and remove potential barriers surrounding the provision of treatment and services to reduce HIV risk, particularly among those at greatest risk. It may be unrealistic for programs to expect that clients will feel free to disclose issues of a sexual nature until a bond of trust has been established with the counselor, which may require more than a few sessions to establish. Providers experienced in the provision of services in emotionally charged areas, such as sexuality, have suggested a “client-paced” approach (Wadsworth et al., 1995). Two-fifths of clients in this study reported that they had received HIV services from their primary counselor; approximately one fifth each received HIV services from a nurse or AIDS outreach worker. More research is needed to assess the impact of various staffing configurations, including client–staff matching based on gender and ethnicity, on delivering these services and reducing HIV-risk behaviors. In addition, both men and women may be reluctant to discuss issues related to sexuality in groups, especially mixed-gender groups. Because of managed care and the current cost-containment atmosphere, programs are now confronting forced decreases in length of stay and pressure to increase the use of groups as the preferred treatment delivery vehicle (Etheridge et al., 1997). An important area for future research is to determine the impact of these constraints on the client–counselor relationship, as well as other factors that may contribute to decreases in HIV-risk behaviors, such as services provided during treatment, client satisfaction, and treatment retention. Several limitations to this study must be noted. The data on receipt of HIV services are based on client self-report. Errors in recall of events occurring over 1 to 3 months of drug treatment are possible; even if individuals received HIV-related information they may not have recognized it as such. Some individuals may have selectively attended to this information in ways that are related to their risk status (e.g., higher-risk individuals may be more likely to have noticed and recalled receipt of HIV-related services). The findings from this study must also be interpreted within the context of the sampling procedure used in DATOS, which was a nonrandom selection of clients entering drug treatment programs. The study reported in this article is further limited by selective attrition of individuals between Intakes
1 and 2 and after 1 to 3 months in treatment, which limits the generalizability of the findings to individuals who are likely to remain in drug treatment for at least these lengths of time. Nevertheless, the study provides evidence that drug treatment programs have far to go in order to fully achieve their potential for reducing risk of HIV transmission/ infection among individuals in drug treatment.
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