Addressing the Impact of Substance Abuse on HIV/AIDS Communities: A SAMHSA Strategy

2. Addressing the Impact of Substance Abuse on HIV/AIDS Communities: A SAMHSA Strategy H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse & Mental Health Services Administration U.S. Department of Health & Human Services 2010 Keeping It Real Conference Baltimore, MD  October 4, 2010

3. “Each of us must take responsibility for reducing our risk of acquiring or transmitting HIV and for supporting affected individuals and communities.  This means getting tested for HIV and working to end the stigma and discrimination people living with HIV face.” President Barack Obama June 27, 2009

4. National HIV/AIDS Strategy “The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.” Vision for the National HIV/AIDS Strategy: Source: http://www.whitehouse.gov/administration/eop/onap/nhas

5. “I am honored to assist the President in achieving the following goals of the [National HIV/AIDS] Strategy: reduce HIV incidence; increase access to care and optimize health outcomes; and reduce HIV-related health disparities in the U.S.”  June 25, 2010 Kathleen Sebelius Secretary U.S. Department of Health & Human Services

6. Behavioral health is essential to health Prevention works Treatment is effective People recover from mental and substance use disorders SAMHSA: Key Messages Pamela S. Hyde, J.D.Administrator, SAMHSA

7. SAMHSA’s Role in Improving the Nation’s Health • Behavioral health services improve health status and reduce health care and other costs to society.  • SAMHSA is charged with effectively targeting substance abuse and mental health services to the people most in need and to translate research in these areas more effectively and more rapidly into the general health care system.  • Continued improvement in the delivery and financing of prevention, treatment and recovery support services provides a cost effective opportunity to advance and protect the Nation’s health.  • SAMHSA has identified strategic initiatives to guide us as we address emerging national trends.

8. SAMHSA’s Strategic Initiatives Prevention of Substance Abuse & Mental Illness Trauma and Justice Military Families – Active, Guard, Reserve, and Veteran Health Reform Housing and Homelessness Jobs and the Economy Health Information Technology for Behavioral Health Providers Behavioral Health Workforce – In Primary and Specialty Care Settings Data Quality and Outcomes – Demonstrating Results Public Awareness and Support SAMHSA’s strategic initiatives are continuing to evolve as we adjust to emerging trends.

9. The Challenge • In 2009, an estimated 22.5 million persons were classified with substance abuse or dependence. • 20.9 million of those needing treatment did not receive it. • And, 4.4% of all adults in this country (an estimated 9.8 million adults, 18 or older) had a serious mental illness in 2008. • 4.1 million of them did not receive mental health services in the past year. • These populations are at greatest risk for transmitting and contracting HIV/AIDS. • They are a critical target for Rapid HIV Testing programs and need to be a critical target for HIV and substance abuse efforts.

10. Past Month Alcohol Use - 2009 Any Use: 51.9% (130 million) Binge Use: 23.7% (59 million) Heavy Use: 6.8% (17 million) (Current, Binge, and Heavy Use estimates are similar to those in 2008) Source: NSDUH 2009

11. Inappropriate Alcohol Use and Risk Behaviors • Alcohol is a mood altering substance. • Used alone or with other substances, it can decrease inhibitions and increase risk behaviors that can lead to transmission of HIV/AIDS, including: • Unprotected sex • Sex with multiple partners • Increased risk of sexual assault • Unintended pregnancy or sexually transmitted diseases Source CDC: Alcohol-Attributable Deaths Report, Average for United States 2001-2005

12. Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002-2009 Source: NSDUH, 2009

13. Concurrent Illicit Drug and Alcohol Use Illicit Drug Use concurrent with Last Alcohol use among Past Month Alcohol Users aged 12+ Percentage of Illicit Drug use Concurrent with Past Month Alcohol Use Source: NSDUH 2009

14. Maryland State Indicators vs. National Average – 2007/2008 Source: NSDUH, 2007-2008 average

15. Past Month Nonmedical Use of Prescription Drugs (Psychotherapeutics) among Persons 12+:2002-2009 Source: NSDUH 2009

16. Past Year Non-medical Use of Pain Relievers – Maryland – 2007/2008 Pain relievers account for the highest nonmedical use of prescription drugs nationally. Past year non-medical use of pain relievers in Maryland was 3.95% compared to 4.8% average use throughout the U.S. In Maryland, young adults (18-25) reported the highest use: 9.74% -- other age groups reported: 5.17% for youths 12-17, 2.83% for adults 26+ Source: 2007-2008 NSDH

17. Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use: 2009 Felt They Needed Treatment and Did Not Make an Effort Did Not Feel They Needed Treatment (693,000) 94.9% 1.8% ( 19.8 Million) Felt They Needed Treatment and Did Make an Effort (371,000) 20.9 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use Source: NSDUH 2009

18. Reasons for Not Receiving Substance Use Treatment: Persons Aged 12+ Those who Needed & Made the Effort to Get Treatment But Did Not Receive Specialty Treatment Did Not Feel the Need for Treatment at the Time Might Cause Neighbors/Community to Have Negative Opinion Might Have Negative Effect on Job Had Health Coverage but Did Not Cover Treatment or Did Not Cover Cost No Transportation/Inconvenient Able to Handle Problem without Treatment Not Ready to Stop Using No Health Coverage and Could Not Afford Cost Source: NSDUH, 2006-2009 combined Percent Reporting Reason

19. Substance Dependence or Abuse among Adults Aged 18 or Older, by Serious Mental Illness in the Past Year: 2008 Source: SAMHSA NSDUH 2008

20. Consequences of Co-occurring Disorders Increased vulnerability to relapse and re-hospitalization More psychotic symptoms Inability to manage finances Housing instability and homelessness Noncompliance with medications and treatment Increased vulnerability to HIV infection and transmissions, as well as hepatitis 20

21. Injection Drug Use and Related Risk Behaviors Although, according to CDC data, HIV transmission through injection drug use has remained steady over the years, the connection between injection drug use and risk behaviors that can lead to HIV infection remain a concern. National Survey on Drug Use and Health (NSDUH) data indicate that 13% of past year injection drug users used a needle that they knew or suspected someone else had used before them. Less than one-third of users cleaned the needle with bleach before using. Source: SAMHSA, National Surveys on Drug Use and Health (NSDUHs) combined 2006-2008

22. Last Use of a Needle to Inject Drugs during Past Year – 2006 to 2008 Source: SAMHSA, National Surveys on Drug Use and Health (NSDUHs) 2006-2008

23. How the Needle Was Obtained the Last Time used to Inject Drugs – 2006 to 2008 Source: SAMHSA, National Surveys on Drug Use and Health (NSDUHs) 2006-2008

24. Substance Abuse & Risk Behaviors Injection drug use is only example of the connection between substance use and abuse and the risk of HIV infection. Any psychoactive substance (“Crack” cocaine, methamphetamines, alcohol & marijuana, etc.) can reduce inhibitions and impair judgment, increasing the risk of HIV infection through sexual contact or injecting drug use. Treating substance abuse disorders without addressing risk behaviors leaves patients at a high risk for HIV infection. 24

25. HIV Infection Among Adults & Adolescents by Sex & Transmission Category - 2008 MALES FEMALES *Heterosexual contact with a person known to have, or be at high risk for, HIV Infection Source: CDC, HIV Surveillance - Epidemiology of HIV Infection (through 2008) Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV reporting since at least January 2006. Maryland is not one of the reporting states.

26. HIV and Minorities According to 2008 CDC data, 132 of every 100,000 African Americans have been diagnosed with HIV infection – the largest racial/ethnic population. Hispanics/Latinos are the second largest population infected, at 52.3 per 100,000. African Americans and Hispanics also make up the 2 largest percentages of HIV diagnoses attributed to injection drug use among racial/ethnic populations – 51.9% and 25.8% respectively. In addition, African Americans comprise 68% of those infected through heterosexual contact, with Latinos/Hispanics, the second largest group, making up 17%. Source: SAMHSA, National Surveys on Drug Use and Health (NSDUHs) 2006-2008

27. Racial & Ethnic Disparities Even when income, insurance and clinical factors were taken into account, minorities received inferior quality services and were less likely to obtain even routine medical service. Minorities are less likely to enter, stay with, or be satisfied with their treatment. Minorities diagnosed with HIV/AIDS experienced delay in obtaining treatment for their disease and were less likely to obtain HAART (highly active antiretroviral therapy) than whites. Sources: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, Institute of Medicine, 2002; Schmidt, L. et al (2006) Unequal treatment: Racial and ethnic disparities in alcoholism treatment services, Alcohol Research and Health, 29(1), 49-54; 27 27

28. Minority AIDS Initiative (MAI) A collaboration of the three SAMHSA Centers: the Center for Substance Abuse Treatment (CSAT) the Center for Substance Abuse Prevention (CSAP) the Center for Mental Health Services (CMHS) Mission: to promote HIV and hepatitis prevention in minority communities through programs that: Prevent and reduce substance abuse, Improve substance abuse treatment, and Promote and improve mental health treatment.

29. SAMHSA’s HIV Portfolio • Center for Substance Abuse Treatment (CSAT) • Targeted Capacity HIV (MAI) • HIV Outreach for Substance Users (MAI) • Substance Abuse and Prevention Block Grant HIV Set-Aside • Center for Substance Abuse Prevention (CSAP) • Minority AIDS Initiative (MAI) • Minority Education Initiatives (MEI) • Center for Mental Health Services (CMHS) • Mental Health Services for HIV+ Individuals

30. CSAT TCE/HIV & HIV Outreach • SAMHSA’s TCE/HIV & HIV Outreach program of 48 grantees is the only national program that addresses the intersection of HIV and substance abuse treatment services. • The program uses a comprehensive approach that integrates recovery support services into the treatment program. • Since 2000, over 132,042 high risk, underserved populations impacted by HIV have been served. • The Intake Coverage rate is 83.5% 30 Source: SAIS, data through 1/22/10

31. The Importance of HIV Testing The CDC estimates that a quarter of the people living with HIV are not aware of their infection. Cohort studies have demonstrated that many infected persons decrease behaviors that help transmit infection to sex or needle-sharing partners once they are aware of their positive HIV status. For that reason, all awarded TCE/HIV & HIV Outreach FY 2008 grantees are required to administer a HIV rapid test to 80% of clients served.   Source: CDC, Divisions of HIV/AIDS Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, updated 8/3/08 31

32. TCE/HIV & HIV Outreach: Demographics 55.5% of clients are male 43.8% are female In addition, 32.5% identify as Hispanic/Latino *rounded figure. Actual: 0.02% 32 Source: SAIS, data through 8/27/10

33. TCE-HIV & HIV Outreach: Top 5 Substances Used Source: SAIS, data through 08/27/10

34. TCE/HIV & HIV Outreach: Outcomes 34 Source: SAIS, data through 8/27/10

35. TCE/HIV & HIV Outreach: Risk Behavior Outcomes 35 Source: SAIS data through 08/27/10

36. TCE/HIV & HIV Outreach: Mental Health Outcomes Source: SAIS data through 08/27/10

37. CSAT – SAPT Block Grant Set-Aside States with an AIDS case rate of 10 or more per 100,000 individuals (“Designated States”) are required to set-aside a certain percentage of the Substance Abuse Prevention & Treatment Block Grant to establish 1 or more projects for early intervention services for HIV. Maryland is a “Designated State” Early intervention services include counseling, HIV testing, and referral services. 37

38. Central East Addiction Technology Transfer Center SAMHSA-funded Addiction Technology Transfer Centers enhance the quality of addiction treatment and recovery services within each region by providing policymakers, providers, consumers and other stakeholders with state-of-the art information through technology translation and transfer activities. Central East ATTC (CEATTC): The Danya Institute, Inc., Silver Spring Includes the Center for HIV, Hepatitis and Addiction Training and Technology (CHHATT) Through professional development materials and “Keeping It Real” Conference – CEATTC continues to be an important resource for raising awareness about addiction-related HIV/AIDS and Hepatitis.

39. CSAP: Minority AIDS Initiative & Minority Education Initiative Grants Currently, the Center for Substance Abuse Prevention funds 139 active MAI and MEI grants MAI and MEI programs deliver prevention of substance abuse and HIV/AIDS services to minority populations. The selected evidence-based interventions include education, data collection, coping strategies and other strategies specific to each grantee organization to prevent the incidence of substance abuse/HIV. Grantees provide HIV testing with pre and post counseling and referral for HIV treatment through established linkages of care.

40. SAMHSA-funded HIV Programs in Maryland Maryland has two Minority HIV Prevention grantees: Strategic Community Services, Inc., Lanham, MD., and Johns Hopkins University, Baltimore

41. CSAP - Minority Education Initiative (MEI) MEI Goal: To increase the number of student tested for HIV/AIDs by creating normative change on minority campuses that reduce the risk behaviors associated with SA/HIV infections and motivate minority students to seek HIV testing. The initiative utilizes peer educators and evidence-based SA/HIV educational programs and environmental change strategies.

42. FY2009 Populations Served Target Campus Populations – 11 HBCU / 2 HSI / 2 Tribal Colleges 96 peer educator training sessions 416 students trained as peer educators 658 student training sessions conducted 17,000 students trained CSAP - Minority Education Initiative (MEI)

43. FY 2009 HIV/AIDS Testing Outcomes 5,986 Students Tested 4,767 Rapid Oral Tests 1,219 Blood Tests 2,419 (40%) of Student Tests were “First Time” Tests CSAP - Minority Education Initiative (MEI)

44. CSAP - American Indian/Alaska Native (AI/AN) HIV/AIDS Initiative (includes: ICMI - Indian Country Methamphetamine Initiative) • Initiative Goal: To increase the capacity of Tribes and Tribal Colleges to conduct peer educator training and implement environmental change strategies that will increase the number of 18-25 year old AI/AN young adults tested for HIV/AIDs

45. Goal: To increase the number of minority young adults tested by HIV/AIDs by connecting community coalitions with the faith community and engaging the faith community in substance abuse and HIV prevention outreach and awareness activities, including HIV testing and counseling. CSAP - Minority HIV/AIDS Faith-Based Initiative

46. FY 2009 HIV/AIDS Testing Outcomes 5,559 HIV Tests 3,597 (65%) of persons tested were “First Time “ Tests 8,639 referrals to human and health related service organizations All projects established linkages to collaborators and partners within the local continuum of care (e.g., Health Depts. Ryan White Funded agencies) CSAP - Minority HIV/AIDS Faith-Based Initiative

47. Hepatitis Prevention The Hepatitis Prevention initiative seeks to demonstrate cost-effective delivery of enhanced health services to an ethnic minority population receiving interventions for opioid dependence within treatment settings with the potential to increase hepatitis vaccination and testing

48. Hepatitis Prevention (cont’d.) 2009/2010 Program Outcomes: To date, 21,825 vaccines/test kits, including Twinrix, Havrix, and Engerix-B have been shipped out for the combined years. Total site usage YTD is 8,868 combined (40.6%) Twinrix – Of the 20,440 sent, 8604 were used (42.09%) Havrix – Of the 330 sent, 86 were used (26.06%) Engerix B – Of the 455 sent, 178 were used (39.12%)

49. Hepatitis Prevention (cont’d.) Other Activities include: Targeted cities with a higher prevalence of minority residents and HAV/HBC/HCV GSA rates negotiated with the pharmaceutical company (GlaxoSmithKiline) for a reduced cost - Free shipping on all vaccine orders Conducted site assessments to help determine the number of vaccines needed by each site given the patient population Accelerated dosing for Twinrix, enabling patients to complete cycle in 30 days, decreasing waste Written documentation accounting for loss or waste of vaccines or test kits

50. Impact of Affordable Care Act (ACA) More people will have insurance coverage Medicaid will play a bigger role in MH/SUD than ever before Focus on primary care and coordination with specialty care Major emphasis on home and community based services and less reliance on institutional care Preventing diseases and promoting wellness is a huge theme What does this mean for those living with HIV/AIDS?