Changes in Testing for Human Immunodeficiency Virus, Sexually Transmitted Infections, and Hepatitis C Virus in Opioid Treatment Programs

Opioid dependence is a risk factor for human immunodeficiency virus (HIV), sexually transmitted infections (STIs), and hepatitis C virus (HCV) infection.¹ Opioid treatment programs, which provide treatment to more than 300 000 opioid-dependent individuals in the United States,² are well-positioned to offer testing for these infectious diseases to a high-risk population. They were among the first venues to offer HIV testing and are more likely to offer HIV, STI, and HCV testing than other drug treatment programs.¹ Private for-profit opioid treatment programs are increasingly widespread and such programs offer on-site HIV testing less often than nonprofit and public programs.³ However, with the 2006 national recommendations for routine opt-out HIV testing,⁴ we hypothesized that the percentage of programs offering on-site testing for HIV, STIs, and HCV would increase.

To determine the percentage of opioid treatment programs offering on-site testing over time, we analyzed the National Survey of Substance Abuse Treatment Services.⁵ The survey is sent to directors of all known drug treatment facilities (response rate, 91.4%-96.5%); survey questions had minor wording changes over time. We tabulated the percentage of opioid treatment programs offering on-site HIV, STI, and HCV testing from 2000 to 2011; there was no survey in 2001. We compared the percentage of for-profit, nonprofit, and public (owned and operated by local, state, tribal, or federal government) programs offering on-site testing over time. Programs with missing data (0.2%-3.9% per year) were excluded. We calculated the relative difference in programs offering on-site testing in 2000 and 2011 using SAS version 9.3 (SAS Institute Inc). P values were calculated using χ² tests for trend. A 2-sided P≤.05 was considered significant. Because the survey is publicly available and contains no patient-level data, the Albert Einstein College of Medicine institutional review board determined this study was not considered human research.

The number of US opioid treatment programs increased from 849 in 2000 to 1175 in 2011. The percentage of programs operating as for-profit businesses increased from 43% to 54%, nonprofits decreased from 43% to 36%, and public programs decreased from 14% to 10%. From 2000 to 2011, the absolute number of programs offering testing for HIV, STIs, and HCV increased but the percentage offering on-site testing for HIV declined by 18% (95% CI, 13%-23%; P < .001) and for STIs by 13% (95% CI, 7%-18%; P < .001). There was no significant change for HCV testing (P = .63; Figure 1).

More than 75% of public programs offered on-site testing for each infection, with no significant change over time. Offering on-site HIV testing declined by 20% (95% CI, 10%-29%; P < .001) among for-profit programs and by 11% (95% CI, 6%-17%; P < .001) among nonprofit programs (Figure 2). Offering on-site STI testing declined by 23% (95% CI, 16%-30%; P < .001) in for-profit programs. Offering HCV testing declined by 13% (95% CI, 3%-22%; P = .002) in for-profit programs and increased by 14% (95% CI, 4%-25%; P < .001) in nonprofit programs.

The proportion of US opioid treatment programs offering on-site testing for HIV and STIs declined substantially between 2000 and 2011, despite guidelines recommending routine opt-out HIV testing in all health care settings, including substance abuse treatment facilities. Declines were most pronounced in for-profit programs, suggesting that persons enrolled in these programs may be at increased risk for delayed diagnosis and continued transmission of HIV, STIs, and HCV.

This study had limitations. Referral-based testing was not recorded; however, referral-based services often do not translate into patient use.⁶ Testing for STIs may be limited to syphilis, which is often required by health departments. The survey is cross-sectional with no identifiers linking responses over time. Because patient-level data are not available, patient requests, use, and opting out of testing cannot be determined.

Opioid treatment programs are important venues for offering testing to high-risk individuals. As the number of for-profit opioid treatment programs increases, and the opioid, HIV, and HCV epidemics continue to intersect, further work is needed to understand and reverse declines in offering on-site testing.

Corresponding Author: Chinazo O. Cunningham, MD, MS, Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467 (ccunning@montefiore.org).

Author Contributions: Dr Bachhuber had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Bachhuber.

Acquisition of data: Bachhuber.

Analysis and interpretation of data: Bachhuber, Cunningham.

Drafting of the manuscript: Bachhuber, Cunningham.

Critical revision of the manuscript for important intellectual content: Bachhuber, Cunningham.

Statistical analysis: Bachhuber.

Obtained funding: Cunningham.

Study supervision: Cunningham.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Cunningham’s husband was recently employed by Pfizer Pharmaceuticals and is currently employed by Quest Diagnostics. No other disclosures were reported.

Funding/Support: This study was supported by grants R34DA031066, R01DA032110, R25DA023021, and AI-51519 from the National Institutes of Health.

Role of the Sponsor: The National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.