Journal of Evidence-Based Social Work, 11:445–459, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1543-3714 print/1543-3722 online DOI: 10.1080/15433714.2012.760968

Integrating Adolescent Substance Abuse Treatment with HIV Services: Evidence-Based Models and Baseline Descriptions Bridget S. Murphy Danya International, Inc., Silver Spring, Maryland, USA

Christopher E. Branson Columbia University College of Physicians and Surgeons and St. Luke’s-Roosevelt Hospital in New York, New York, USA

Judith Francis Pima Prevention Partnership, Tucson, Arizona, USA

Gretchen Chase Vaughn Vaughn Associates, New Haven, Connecticut, USA

Alison Greene University of Arizona Southwest Institute for Research on Women (UA-SIROW), Tucson, Arizona, USA

Nancy Kingwood GBAPP Inc., Bridgeport, Connecticut, USA

Gifty Ampadu Adjei Department of Psychology, University of Rhode Island, Kingston, Rhode Island, USA

Adolescents with substance use disorders are at high risk for contracting Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) and other sexually transmitted infections (STIs). Adolescence is the period of sexual maturation that compounds the issues associated with infection transmission for this risk-taking group. Integrated treatment models for implementing HIV education, counseling, and testing is a promising approach. This study describes four substance abuse treatment programs of varying levels of care that integrated HIV services for adolescents. Bridget S. Murphy conducted the research reflected in this article while affiliated with the University of Arizona, Southwest Institute for Research on Women, Tucson, Arizona. No grants or contracts awarded to Danya International, Inc. supported this research. Gretchen Chase Vaughn, PhD, and Gipty Ampadu Adjei, MA, through Vaughn Associates, provided the program evaluation for the BPT Program at GBAPP Inc. Address correspondence to Bridget S. Murphy, E-mail: [email protected]

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Additionally, the evidence-based substance abuse treatment and HIV models are discussed and the baseline characteristics presented. The authors provide a discussion and offer recommendations for service implementation and additional research. Keywords: HIV, adolescents, sexually transmitted infections, substance use, sexual risk, evidencebased models

INTRODUCTION Numerous studies have established the relationship between substance use and risky sexual behaviors (Chan, Passetti, Garner, Lloyd, & Dennis, 2011; Levy et al., 2009; Tubman, Oshri, Taylor & Morris, 2011). Investigators have found higher rates of gonorrhea and chlamydia among adolescents that use alcohol or illicit drugs (Anderson & Mueller, 2008; Gardner & Steinberg, 2005; Liau et al., 2002). Additionally, adolescent females and minority populations (e.g., racial/ethnic, sexual orientation, geographic, and disabilities) are disproportionately affected by Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) and sexually transmitted infections (STIs) and are underrepresented in substance abuse treatment (Austin & Wagner, 2010; Butler, Ruiz, & Davis, 2011; Centers for Disease Control and Prevention [CDC], 2008; Kilpatrick et al., 2000). Government surveillance data reveal significant regional, ethnic/racial, and gender differences in prevalence rates of HIV/AIDS. Rangel Gavin, Reed, Fowler, and Lee (2006) examined the regional, racial/ethnic, and gender differences with regard to HIV/AIDS rates using CDC prevalence data by three age groups: (a) 13–15, (b) 16–19, and (c) 20–24. The authors hypothesized that given the significant developmental differences during this period HIV/AIDS rates would also reflect significant differences. The investigators found that (a) cases significantly increased between 1999 and 2003 for 16–19 and 20–24 year olds, (b) the burden of the HIV/AIDS cases are in the south and northeast United States, (c) the percent of females with HIV/AIDS was lower (but not statistically) as compared to males with the exception of females in the 13–15 year old category where females had the highest proportion of HIV infection, and (d) three-quarters of newly diagnosed HIV infections were among Black and Hispanic youth. The prevalence rates in the United States also indicate that young people (12–25 years of age) account for the overwhelming majority of newly diagnosed STIs that if left untreated increase risks for contracting HIV (CDC, 2008). The CDC (2008) has identified eight primary factors that place youth at risk for HIV including: (a) early age of sexual initiation, (b) heterosexual sexual contact particularly for females and minority females, (c) men who have sex with other men (MSM), (d) undiagnosed or untreated STIs, (e) substance abuse, (f) poverty and out-of-school, (g) the coming of age (adolescence) of HIV positive children (who contracted HIV perinatally), and (h) lack of awareness. Investigators have also found other risks factors such as: (a) multiple system involvement (e.g., juvenile justice and child welfare; Morris, Baker, Valentine, & Pennisi, 1998; Ruiz, Stevens, Fuhriman, Bogart, & Korchmaros, 2009; Teplin, Mericle, McClelland, & Abram, 2003) and (b) history or current issues of co-occurring disorders and trauma (Stevens, Murphy & McKnight, 2003; Walton et al., 2011). Numerous studies have shown that adolescents with substance use disorders have many of these risk factors. For example, Chan and colleagues (2011) examined the HIV risk factors of 9,519 adolescents admitted to substance abuse treatment between 2002 and 2006 and found that 60% of the adolescents were engaged in at least one sexual- or needle-risk behavior during the year prior to treatment entry. The most common risk factors were sex with multiple partners, sex under the influence of alcohol or drugs, and unprotected sex. Finally, adolescents with

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substance dependence and other comorbid mental health problems were at increased odds for HIV risk. In light of the high rates of co-occurring HIV risk behavior and substance use, it appears that enhancing substance abuse treatment with HIV/STI screening, education, and testing services represents a promising approach to reducing the spread of HIV/AIDS and improving overall health among high-risk adolescents. Specific service enhancements suggested by researchers include HIV/STI education, testing, and risk reduction counseling (Chan et al., 2011; Knudsen & Oser, 2009). While substance abuse treatment alone has been shown to reduce rates of HIV risk behavior among teens (Joshi, Hser, Grella, & Houlton, 2001), there is little published research on the efficacy of models of integrated substance abuse and HIV risk treatment (Stevens, LeybasAmedia, Bourdeau, McMichael, & Nyitray, 2006). This is not surprising since Knudsen and Oser (2009) found that out of 149 “adolescent-only,” publicly and privately funded treatment programs only (a) 56% provided an HIV assessment, (b) 57% provided HIV prevention (primarily educational session with regard to how HIV is transmitted), and (c) 34% offered HIV testing. The investigators argued that these are missed opportunities for early intervention for a high-risk population. A recently published study examined the effects of one-session on HIV education that was embedded into evidence-based treatment (Hops et al., 2011). Hops and colleagues (2011) added one HIV educational session to a cognitive behavioral therapy (CBT) or integrated behavioral family therapy (IBFT). The investigators found no direct effect of the HIV session on the sexual risk behaviors measured (e.g., unprotected sex and sex while high on drugs or alcohol). However, the investigators did find effects on sexual risk behaviors related to both the CBT and IBFT models with the CBT demonstrated superior effects as compared to IBFT. Hops et al. argued that evidence-based substance abuse treatment models might be positively affecting multiple risk behaviors in addition to substance use. Yet, other investigators have argued that complimenting evidence based substance abuse treatment with comprehensive sexual health education that is theory-based and acknowledges the socioecological contextual issues (e.g., individual, familial, psychosocial, community, and culture) provides for more durable and sustained effects on risky sexual behaviors (Kirby, 2002; DiClemente et al., 2008). The Substance Abuse and Mental Health Services Administration (SAMHSA) has the National Registry of Evidence-Based Programs and Practices (NREPP), which has “more than 210 interventions supporting mental health promotion, substance abuse prevention, and mental health and substance abuse treatment” (SAMHSA, 2011, p. 1). Using the web site’s advanced search feature, the authors found 10 substance abuse or mental health interventions that reported positively reducing sexual risk behaviors. Seven of the ten indicated incorporating a specific session or module designed to address high-risk sexual behaviors. Similarly, the CDC has the Diffusion of Effective Behavioral Interventions (DEBIs) that were “designed to bring sciencebased, community, group, and individuals-level HIV prevention interventions to community-basedservice providers and state and local health departments” (Danya International, 2012). Out of the 30 interventions reviewed on the DEBI website only five (17%) specifically indicated that they were developed for adolescents and none described addressing substance use. Between these two registries there are only seven interventions tested with adolescents that have been found to improve both substance use and sexual risk behaviors. The limited number of available models could be contributing to the reasons why very few treatment providers are addressing HIV/STI risks with adolescents. In summary, adolescents with substance use disorders are at increased risk for HIV and STI. Moreover, females and minority groups are disproportionally affected by HIV and STIs and also underrepresented in substance abuse treatment. Despite the promise of enhancing substance abuse treatment with HIV prevention services, there is limited literature describing or evaluating such integrated treatment models. The current study helps to address this gap by describing four sites

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TABLE 1 Evidence-Based Substance Abuse and HIV Prevention/Intervention Models

Models (listed alphabetically) Adolescent Community Reinforcement Approach a Assertive Continuing Care b Becoming a Responsible Teen (BART)c;d Be Proud, Be Responsible—A Safer Sex Curriculuma Motivational Enhancement Therapy/ Cognitive Behavioral Therapya;c;d Sanctuary Model b Seeking Safety b SIROW-HEYb RESPECTa The Matrix Model b

Other Risk Factor (e.g., trauma and co-occurring)

Substance Abuse

HIV/STI Risks

3 3 — —

— 3 3

—

Godley et al. (2001) Godley et al. (2006) Fisher & Fisher (1992) Select Media (1992)

3

—

3

Sample & Kadden (2001)

— 3 3 — 3

— — 3 3 —

3 3

Bloom (1994) Najavits (2007) Greene et al. (2011) Kamb et al. (1998) Rawson et al. (2005)

Source

3 3

3

Note. Check mark indicates that the model addresses the issue and a dash indicates the model does not. SIROW-HEY D Southwest Institute for Research on Women-Health Education for Youth. a Outpatient. b Residential. c Hospital-based. d School-based.

that were funded to increase substance abuse treatment capacity by providing HIV prevention, treatment, and testing to high-risk target populations and communities.

METHODS All four sites (see site descriptions below) were funded for 5 years to expand substance abuse treatment by providing HIV/AIDS education and testing through SAMHSA’s Targeted Capacity Expansion Program for Substance Abuse Treatment and HIV/AIDS Services (TCE-HIV; Thompson, 2010). All four projects targeted ethnic minority adolescents yet differed in setting/level of care (hospital, residential, outpatient, school-based), geographic location, and specific interventions employed (see Table 1 and Table 2). The program and evaluation protocol of each site was approved by its respective local Institutional review board (IRB). All sites collected informed consent from participating youth and their parents/guardians. TABLE 2 HIV and STI Services Provided by Site Service/Setting HIV testing STI testing HIV/STI education Assistance with partner notification Family/caregiver education

Hospital-Based

Residential

Outpatient

School-Based

X

X X X X X

X

X

X

X

X

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Hospital-Based (New York, New York) The Adolescent Screening, Assessment, and Treatment (ASAT) program, also known as the Discovery Center, aimed at addressing the high rates of co-occurring HIV risk behavior and substance use among low-income youth at risk for or living with HIV/AIDS in New York City, New York. The communities targeted by ASAT have significantly higher rates of new HIV/STI infections, teen pregnancies/births, and unmet substance abuse and mental health needs compared to the citywide average (New York City Department of Health and Mental Hygiene, 2005, 2006). The program was housed at St. Luke’s-Roosevelt Hospital Center, a large urban hospital, and involved collaborations with multiple programs/departments within the organization and throughout the local community. Primary referrals sources included juvenile justice, child welfare, and mental health treatment providers. The Discovery Center offered outpatient early intervention (American Society of Addiction Medicine [ASAM] Level 0.5; Mee-Lee et al., 2001) and substance abuse treatment (ASAM level 1) services for youth, both of which addressed substance use and sexual risk taking. Youth in the treatment program received Motivational Enhancement Therapy/Cognitive Behavioral Therapy (MET/CBT; Sample & Kadden, 2001), an evidence-based intervention for substance abuse, supplemented with HIV-risk reduction modules. The early Intervention program focused on prevention of substance use and sexual activity/risk taking among younger adolescents. This program incorporated elements of MET/CBT, along with Becoming A Responsible Teen (BART; Fisher & Fisher, 1992), a CDC DEBI program for HIV prevention. Additional services offered to all youth included: referral to onsite rapid HIV testing and risk reduction counseling, referral to local adolescent sexual healthcare centers, and free condom distribution. Residential Treatment (Tucson, Arizona) Project Determining Another Path (DAP) provided HIV prevention, sexual health education, and substance abuse treatment services to youth and families in community-based settings in Pima (urban) and Cochise counties (rural) in Arizona. In Pima County, services were embedded within a residential treatment setting (ASAM level 3.5). Several evidence-based practices are used including: (a) Matrix Model (addresses client substance use; Rawson, Obert, McCann, & Ling, 2005), (b) Sanctuary Model (address trauma-informed organizational structure; Bloom, 1994), (c) Seeking Safety (addresses client trauma and substance use; Najavits, 2007), (d) Southwest Institute for Research on Women—Health Education for Youth (SIROW-HEY; addresses sexual health and substance abuse; Greene, Springer, & Ruiz, 2011), and (e) Assertive Continuing Care (ACC; continuing care; Godley, Godley, Karvinen, Slown, & Wright, 2006). Within the Cochise County setting services were embedded within an independent living program for youth with substance use problems (ASAM level 0.5). Project DAP provided sexual health education, continuing care, and HIV/STI assessment, counseling and testing. SIROW-HEY provides (a) 8–16 session HIV prevention and comprehensive sexuality education curriculum for youth, (b) a 2-session parent/caregiver curriculum, (c) on-site HIV/STI counseling and testing, (d) weekly visits to the HIV/STI clinic, (e) distribution of safer-sex protection kits, (f) staff trainings related to intersections of substance abuse and HIV risks, and (g) continuing care to assist youth in the community with relapse prevention, life skills, and to reinforce healthy behaviors and practices. To effectively embed HIV and sexual health services into substance abuse treatment, it was necessary to develop strategies to expand the knowledge, understanding, and collective approach between collaborators. Through regular communications, cross-trainings, and meetings Project DAP aimed to merge the differing perspectives among collaborators coming from the diverse professional fields (substance abuse treatment, county health departments, and a university research

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institute) in order to successfully implement a program providing HIV prevention, sexuality education, and substance abuse treatment in a community-based setting. Outpatient (Tucson, Arizona) Sin Miedo (translated from Spanish means “without fear”) is a 5-year grant funded project focusing on outpatient treatment needs of justice-involved and low-income teens with substance abuse and high HIV-risk behaviors in Pima County, Arizona. The project was integrated into Sin Puertas, a community-based adolescent treatment center operated by Pima Prevention Partnership (PPP), a 19-year-old nonprofit agency serving high-risk youth and families in southern Arizona. Along with substance abuse treatment, the Sin Miedo project provides HIV prevention and sexual health education to youth aged 12–18 years, referred primarily by the Pima County Juvenile Court Center (PCJCC). HIV risk behaviors are often intertwined with substance use, mental health issues, violence, poverty, and crime for these justice-involved adolescents. Of youth on probation in Pima County in 2010, 57% of standard probationers and 83% of intensive probationers were assessed with significant mental health issues, while 79% of all youth on probation had used alcohol or drugs in the past year (PCJCC, 2011). Of 1,026 justice-involved youth referred to Sin Puertas since 2007, 70 were assessed with HIV risk behavior and 16% scored high on an HIV risk assessment scale. At intake, Sin Miedo clients are assessed for co-occurring mental health problems and levels of crime, violence, victimization, trauma, and sexual/HIV risk before a treatment plan is developed by staff. Treatment options include group and individual outpatient and intensive outpatient modalities: a day support program based on the MET/CBT 5 which included groups on site and in the community; Adolescent Community Reinforcement Approach (A-CRA; Godley et al., 2001), individual and family sessions; co-occurring mental health problems groups based on SAMHSA’s TIP 42 (Center for Substance Abuse Treatment [CSAT], 2005) and the Hazelden Co-occurring Disorders Family Program series (Dartmouth Psychiatric Research Center, 2008); intensive cognitive behavioral therapy groups based on SAMHSA TIP 32 (CSAT, 1999) and the Hazelden Adolescent Recovery Plan curriculum (Biddulph, 1999), a trauma-informed group for girls using the research-based Voices: A Program of Self-Discovery and Empowerment for Girls (Covington, 2004), and a peer-led recovery aftercare group. Treatment staff have a choice of evidence-based sexual health curricula, including BART and Be Proud! Be Responsible! A Safer Sex Curriculum (Select Media, 1992). Specific HIV risk behaviors are addressed with RESPECT: Brief Counseling (Kamb et al., 1998), a brief evidence-based approach to HIV risk reduction using motivational interviewing techniques to enhance clients’ understanding of their risk and to help them negotiate an individualized plan for risk reduction. Youth are also offered the opportunity for HIV screening on site or by referral. School-Based (Bridgeport, Connecticut) The Bridgeport Partners For Teens (BPT), led by Greater Bridgeport Area Prevention Program (GBAPP Inc.), is a comprehensive substance abuse and HIV services program developed to reach minority and re-entry youth, aged 12–17 years, over a five-year period through an extensive inschool and after-school collaborative effort in Bridgeport, Connecticut. GBAPP Inc., a private nonprofit agency with 30 years providing youth services, partnered with Connecticut Renaissance (a substance abuse treatment facility), local schools, and community stakeholders. The program goal of reducing the transmission of HIV and alcohol, tobacco, and other drugs (ATOD) use among minority adolescents, by providing outreach, prevention and treatment services to at-risk youth as well as youth who are currently drug users and/or in recovery.

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HIV prevalence is disproportionately distributed in Connecticut; 7.4 times higher in Blacks and 5.6 times higher in Hispanics than in Whites (Connecticut Department of Public Health, 2009). In the city of Bridgeport, Blacks comprised 52% and Hispanics comprised 39% of HIV infection cases diagnosed in 2009. Youth below 20 years of age in the state represent 9% of persons living with HIV infection; however, the majority of STI cases (e.g., chlamydia 69% and gonorrhea 55%) occur among young people aged 15–24 years (Connecticut Department of Public Health, 2009). The youth entering the BPT program are sexually active (70% report sex during lifetime), engage in sexual risk behaviors (more than 50% have more than two partners), and more than 50% report they are likely to engage in sex in the next 3 months. At intake 30% of youth used illegal drugs (past 30 days) an average of 14 days. Services available include peer-to-peer outreach and risk reduction to adolescents at high risk for HIV infection and substance use, HIV testing, individual behavior risk assessment, group-level risk reduction education, and substance abuse treatment. The risk reduction education follows the evidence-based curriculum, BART and the substance abuse treatment, provided by Connecticut Renaissance, is MET/CBT 5. Outreach, recruitment, treatment, and HIV testing occur at a local high school in partnership and support of the board of education. The certified prevention counselor offers the OraQuick rapid HIV testing methods to students enrolled in the school based health center. All project participants identified as having unmet medical and/or supportive service needs are referred to appropriate agencies for services and case management will follow-up for up to 6 months post-enrollment. This innovative approach offers students in active addiction and/or early recovery support and services during school hours. Description of HIV Evidence-Based Models The four sites used four different evidence-based models for addressing HIV risk behaviors which were (a) BART, (b) Be Proud! Be Responsible! A Safer Sex Curriculum, (c) RESPECT, and (d) SIROW-HEY. BART. BART is an eight-session HIV prevention program designed primarily for Black adolescents in non-school, community-based settings. While it was primarily developed for Black adolescents, it has also been used with other racial/ethnic groups. The primary objectives of BART are for adolescent participants to (a) state accurate information about HIV and AIDS, including means of transmission, prevention, and current community impact; (b) clarify their own values about sexual decisions and pressures; and (c) demonstrate skills in correct condom use, assertive communication, refusal, information provision, self-management, problem-solving, and risk reduction. BART uses social learning and self-efficacy theory as the framework to empower adolescents to learn about HIV and related issues but to share what they have learned with their friends. Curriculum topics include HIV/AIDS, making sexual decisions and understanding values, developing and using condom skills, learning and practicing assertive communication skills, personalizing the risk, spreading the word, and taking BART with you. One efficacy study on BART found that adolescents participating in the experimental group had higher levels of knowledge about AIDS, more likely to use condoms, and less likely to engage in oral, vaginal, or anal sex as compared to the control (Fisher & Fisher, 1992). Be Proud! Be Responsible! A Safer Sex Curriculum. Be Proud! Be Responsible! is a CDC and Resource Center for Adolescent Pregnancy Prevention (ReCAPP) evidence-based program that “is designed to give adolescents the knowledge, motivation, and skills necessary to reduce their risk for STDs, including HIV” (Jemmott, Jemmott, Fong, & Morales, 2010, p. 271). The program targets Black males or inner city youth. One experimental study detected reduced frequency of sex,

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reduced number of sexual partners, reduced number of female partners also involved with other men, increased condom use, and reduced incidence of heterosexual anal intercourse (Jemmott, Jemmott, & Fong, 1992). RESPECT. RESPECT is a 2-session intervention targeting individuals aged 14 years and older. The 2 sessions are 20 minutes in length and are conducted in a one-on-one format. RESPECT was developed primarily for use in HIV and STI testing clinics but has been used in other settings. The sessions are designed to improve clients’ perceptions of risk while increasing knowledge for risk reduction. “Core elements of the intervention are to conduct one-on-one counseling using the RESPECT protocol, utilize a ‘teachable moment’ to motivate clients to change risk-taking behaviors, explore circumstances and context of a recent risk behavior to increase perception of susceptibility, negotiate an achievable step which supports the larger risk reduction goal, and implement and maintain quality assurance procedures” (Danya International Inc., 2012). The intervention uses a structured protocol. One study with adults found that men and women in the intervention condition reported significantly greater condom usage and had fewer new sexually transmitted infections (Kamb et al., 1998). SIROW-HEY. SIROW-HEY is a manualized HIV and sexual health education program for adolescents between the ages of 13 and 18 years and their parents/caregivers. The HEY intervention is comprised of six components: (a) group-based HIV, STI, and sexual health education sessions; (b) individualized HIV and STI prevention planning sessions; (c) individual parent/caregiver and family discussion sessions; (d) linkages and access to clinical health services; and (e) engagement in prosocial activities. Using the Health Belief Model and social ecology as its theoretical framework, SIROW-HEY aims to improve: (a) knowledge with regard to pregnancy, puberty, and reproductive/sexual anatomy and physiology, HIV/AIDS, STIs, substance use and sexuality, safer sex protection methods, communication skills, and relationships; (b) access to clinical services such as testing, prevention, and care for pregnancy, sexually transmitted diseases, and HIV/AIDS; and (c) sexual health/wellness outcomes such as increased barrier protection usage, self-esteem/efficacy, parent communication, and reduced number of partners. Evaluation results have demonstrated increases in adolescent knowledge, decreases in risky sexual behaviors, and increases in barrier protection usage (SIROW, 2010). Government Performance Results Act (GPRA) Measures All projects administered the Government Performance and Results Act (GPRA; SAMHSA, 2012) measure participants at baseline and 3- and 6-month follow-ups. The GPRA was designed by SAMHSA to monitor the effectiveness of grant funded programs and assesses seven areas of client functioning, including stable housing, drug abstinence, and social connectedness. SAMHSA requires all grantees to collect this uniform set of data from each individual served and enter it into a web-based system (Mulvey, Atkinson, Avula, & Luckey, 2005). The variables used for the descriptive analyses are provided on Tables 3–5 and are from the GPRA items within the demographics, mental and physical health problems (e.g., HIV risks and testing), and alcohol and drug use sections. Data Analysis All data were analyzed using Statistical Package for the Social Sciences (SPSS) using descriptive statistics. There were some limitations to data sharing across sites due to IRB restrictions. As such, each site analyzed its own data. This limited the types of analyses that could be completed.

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TABLE 3 Sample Characteristics by Program (N D 1,057)

Age Female Race/ethnicity Latino African American Asian Native Hawaiian/Pacific Islander Alaskan Native White American Indian Currently houseda Institutionalized Shelter/homeless Has children Enrolled in school Employed part-/full-time On parole/probation

Hospital-Based (N D 264)

Residential (N D 322)

Outpatient (N D 198)

School-Based (N D 273)

14.7 (1.5) 39%

15.8 (1.1) 10%

15.9 (1.7) 23%

15.7 (1.3) 60%

57% 38% 0% 0% 0% 5% 0% 100% 0% 0% 1% 94% 7% 21%

47% 7% 1% 1% 1% 49% 14% 44% 54% 2% 4% 34% 7% 85%

68% 5% 0% 1% 1% 33% 11% 95% 4% 1% 6% 65% 10% 78%

46% 48% 3% 1% 0% 14% 2% 99% 0.4% 0% 2% 97% 12% 7%

Note. Percentages are reported for categorical variables. Mean (SD) are reported for continuous variables. a Percentage of clients housed, in shelter, street/outdoors, and institution.

RESULTS As shown in Table 3, there were site differences in the age of the adolescents with the hospitalbased youth being the youngest (mean age D 14.7 years) and the residential being the oldest (mean age D 15.8 years). The percentage of male participants ranged from 40–90% across sites. Participants were predominately Latino (46–68%), non-Latino Whites (5–49%), or Black (5– 48%). There were differences in the specific Latino ethnic groups served by each site, with the TABLE 4 Past Month HIV Risk Behavior by Program (N D 1,057)

Sexually active Number of sexual contactsa Unprotected sexa Unprotected sex with HIVC partner a Unprotected sex with IDU a Unprotected sex while intoxicated a Unprotected sex ratioa Tested for HIV-lifetime Know HIV test results b

Hospital-Based (N D 264)

Residential (N D 322)

Outpatient (N D 198)

School-Based (N D 273)

36% 7.0 (13.0) 40% 0 0 31% .21 (.33) 32% 86%

24% 6.5 (6.4) 57% 0 0 25% .40 (.43) 57% 98%

60% 6.8 (10.3) 58% 0 0 25% .42 (.44) 21% 98%

37% 4.9 (5.7) 43% 0 0 8% .35 (.44) 29% 98%

Note. Percentages are reported for categorical variables. Mean (SD) are reported for continuous variables. IDU D injection drug user. a These analyses are limited to participants reporting past-month sexual activity. b These analyses are limited to participants who reported being tested for HIV.

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TABLE 5 Past Month Substance Use by Program (N D 1,057)

Alcohol use 5 drinks a 4 drinks a Illicit drug use Used alcohol and drugs on same day Days of alcohol usea Days of illicit drug useb Experienced stress related to AOD use Gave up important activities due to AOD use

Hospital-Based (N D 264)

Residential (N D 322)

Outpatient (N D 198)

School-Based (N D 273)

34% 17% 14% 44% 17% 4.6 (5.9) 15.1 (11.4) 20% 14%

30% 88% 15% 47% 24% 6.6 (7.3) 14.0 (10.3) 37% 26%

38% 68% 34% 54% 23% 4.4 (4.6) 13.2 (10.4) 27% 18%

26% 60% 31% 32% 14% 5.1 (6.4) 13.6 (11.8) 6% 7%

Note. Percentages are reported for categorical variables. Mean (SD) are reported for continuous variables. AOD D alcohol and other drugs. a These analyses are limited to participants who reported past month alcohol use. b These analyses are limited to participants who reported past month illicit drug use.

residential and outpatient sites (both located in Arizona) serving almost entirely Mexican youth (92–99% of all Latinos), the hospital-based site (located in New York City) serving large numbers of Puerto Rican and Dominican youth, and the school-based site (located in Connecticut) serving mostly Puerto Rican youth. Rates of school enrollment varied across sites, from a low of 34% for residential participants to 97% of school-based participants. The percentage of youth currently on probation/parole also differed among sites, ranging from 7–85%. HIV Risk Behavior There were notable differences in the patterns of past month sexually activity and HIV risk behavior across sites (see Table 4). The majority of adolescents in the outpatient program (60%) reported past month sexual activity, with lower rates (24–37%) for the school, residential, and hospital-based programs. A large percentage of adolescents across programs reported engaging in unprotected sex during the past month (40–58%). There were differences among the sites in terms of the proportion of unprotected sexual contacts (21–45%). In terms of other sexual risk taking, none of the participants in the current study reported past-month unprotected sex with an injection drug user or HIV positive partner, while 8–31% of participants reported having unprotected sex while they or their partner were under the influence of alcohol or drugs. Rates of HIV testing were much higher among youth in residential treatment (57%) compared to youth from the other three settings (21–32%). Most youth who took an HIV test were aware of their test results (86–98%). Substance Use The prevalence of alcohol use was fairly similar across sites, with 26–38% participants reporting past month drinking. However, the rates of past month binge drinking (5 drinks in one sitting) among participants who used alcohol were much lower in the hospital-based programs (17%) compared to the school (60%), outpatient (68%) and residential (88%) programs. The number of days the adolescents reported drinking during the previous 30 days did not vary significantly by site. One consistent finding across settings was the higher rates of illicit drug use compared to

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alcohol use, with the mean days of drug use (13.2–15.1) approximately two to three times greater than the mean days of alcohol use (4.4–6.6).

DISCUSSION This article contributes to the literature in that, it describes four sites, of varying levels of care that implemented evidence based substance abuse and HIV/STI interventions with adolescents. The models described have been previously tested and shown to be effective for reducing substance abuse and HIV/STI behaviors. Unfortunately, most of the interventions described were either specific for substance use or HIV with only one model addressing both. Recognizing the multitude of issues adolescents with substance use disorders have more integrated evidence-based models are called for. All sites were able to engage more than 50% racial and ethnic minorities. The school-based program was able recruit the highest percentage of females (60%) as compared to the other modalities. This is important since schools may be better locations to identify females in need of substance abuse treatment and HIV/STI prevention as compared to the typical substance abuse treatment referral sources (e.g., juvenile justice). All or almost all of the hospital-based, outpatient, and school-based adolescents were housed at intake with less than half of the residential adolescents being housed at intake. More than half of the residential adolescents were institutionalized with fewer of the hospital-based, outpatient, and school-based youth reporting being institutionalized. The vast majority of adolescents in residential and outpatient settings were on probation/parole at intake. The differences in demographics are interesting as they highlight not only the differences by level of care but also the regional differences (e.g., Arizona v. New York). Moreover, the differences in the demographics prompted sites to make adaptations to the interventions or to emphasize certain material. For example, the school-based site provided additional information on gender-specific issues whereas the residential site discussed specific HIV risks associated with institutionalization (e.g., tattooing and sexual violence). While outpatient treatment showed the highest percentage of sexually active adolescents, the hospital-based site had the highest number of sexual contacts. The greatest HIV risk factors reported were having unprotected sexual contacts and having unprotected sexual contacts while intoxicated. Given this, the sites integrated HIV education within the context of substance treatment and substance using behaviors. For example, the HIV evidence-based models provide adolescents with the skills to communicate with their sexual partners’ about drug and alcohol use addition to condom or other barrier protection usage. Additionally, it is relevant that the interventions provide adolescents information about the intersection between sexual behavior while under the influence of alcohol and other drugs and HIV risks. Adolescents may be using alcohol or illicit drugs to reduce inhibitions during sex or to reduce anxiety due to past traumas while engaging in sexual activity. As such, interventions should incorporate strategies to help adolescents recognize the differences between healthy and unhealthy sexual behaviors and what might be some the behavioral antecedents associated with engaging in risky sex. The use of alcohol and illicit drugs is pretty similar across sites with greater numbers of adolescents reporting illicit drug use. Yet, the percent of adolescents that reported binge drinking during the previous 30 days (5 or more drinks in one sitting) is considerable. Cooper (2002) conducted a meta-analysis with regard to alcohol use and risky sexual behaviors. She found that there was generally a weak effect detected for associations between drinking and decreased use of protection methods (e.g., condoms) with the exception to younger, sexually inexperienced adolescents. Clearly, evidence-based models for conducting HIV interventions with adolescents must consider and address the specific developmental issues associated with substance use and HIV risks. More specifically, the interventions should help adolescents to develop healthy behavioral

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plans if he/she is in a high-risk drinking or drug using situations that might include a sexual encounter (e.g., role playing and condom availability).

Strengths and Limitations The strengths to this article include the descriptions of the four levels of care, the evidence-based practices used, and the large sample size. However, due to IRB restrictions not all sites were able to share deidentified data. Given this we were limited in the types of analyses we conducted. Yet, this descriptive article is substantive since there is so little in the literature that describes models for providing substance abuse treatment and HIV education, testing, and counseling.

Important Social Work Considerations for Implementing HIV Prevention in Substance Abuse Treatment Implementing HIV education, testing, and counseling in substance abuse treatment with adolescents can present challenges. First, issues of consent and reporting are important to consider. The age at which an adolescent can get HIV testing without parental permission varies state to state. Additionally, states vary in terms of what types of confidential information (as compared to anonymous) is mandated to be forwarded to state reporting agencies. Making sure that these issues are communicated to adolescents and their guardians is critical so they are able to make informed decisions about testing. Second, it is relevant for organizations to have protocols in place for adolescents who test HIV positive while in treatment. More specifically, if a substance abuse treatment organization provides testing services important organizational considerations includes (a) disclosure, (b) medical treatment, and (c) clinical supports. Third, it is important to train substance abuse treatment personnel on the issues of HIV and sexual health education. Training treatment personnel on factual information about HIV and STI transmission is primary, but it is equally important to provide training on (a) human sexuality development, (b) communication in sexual/romantic relationships, and (c) strategies for discussing these topics with adolescents and families. Making sure that all treatment personnel have a basic level of knowledge and skills ensures that adolescents are receiving consistent and accurate messages.

CONCLUSIONS Adolescents with substance use disorders are at high risk for contracting HIV and other STIs. Developmentally, adolescence is the period of sexual maturation that compounds the issues associated with infection transmission for this risk-taking group. Using an integrated treatment approach for implementing HIV education, counseling, and testing is a promising model for reducing risks among adolescents. The existing evidence-base for interventions that address HIV for adolescents is limited and requires additional study.

ACKNOWLEDGMENTS The authors acknowledge Jutta Butler for encouraging the development and submission of this manuscript. We also acknowledge all the youths and families that participated in the services and evaluation.

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FUNDING This research was supported by the Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT). The views expressed here are the authors and do not necessarily represent the official policies of the Department of Health and Human Services; nor does the mention of trade names, commercial practices, or organizations imply endorsement by the U.S. government.

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