Adaptations across Clinical Sites of an Integrated Treatment Model for Persons with HIV and Substance Abuse

Abstract

Substance use disorders are common among people living with HIV (PLWHA), and PLWHA with untreated substance use are less likely to receive antiretroviral therapy (ART) or achieve viral suppression when ART is prescribed. Integrated behavioral and medical interventions are one approach used to treat complex chronic illnesses, including HIV and substance abuse (SA). As the potential benefit for integrated HIV-substance abuse treatment is recognized, the number of providers attempting to integrate care is growing. Integrated care models can range from coordinated to colocated to fully integrated models. Providers need a better understanding of these implementation options for HIV-substance abuse treatment and how they impact providers of different disciplines. Between April and November 2006, interviews exploring the process of implementing an integrated HIV-substance abuse intervention were completed with clinic staff at three diverse HIV clinics in North Carolina. Key differences in implementation between sites were found. The degree of integrated care between sites ranged from colocated to integrated, and clinic staff perceived each integrated model to have advantages and disadvantages. Recommendations for implementing HIV-SA integrated care are made.

Introduction

S ubstance use disorders are present in 20%–40% of HIV-infected people.^1,2 The interactive dynamics of substance use and HIV impact the successful treatment of each morbidity. Individuals with untreated substance use are less likely to receive antiretroviral therapy (ART) or achieve viral suppression when ART is prescribed.³ Conversely, lack of effective medical care may interfere with efforts to reduce or abstain from substance use. The combined stigma of HIV and substance abuse (SA) make accessing treatment difficult⁴ and the complexity of treating both chronic illnesses further impedes effective care.

Integrated behavioral and medical interventions are one approach used to treat complex chronic illnesses. Most Americans receive behavioral health treatment integrated into primary care settings.⁵ Outcomes of integrated medical-mental health models include improved diagnosis of mental illness, reduced stigma, and augmented follow-up.^6
–8 A review of integrated medical–alcohol treatments suggested that they can reduce alcohol use and mortality, especially if alcohol use, affects the medical condition.⁹ Integrated care has also been related to greater utilization of HIV health services.¹⁰ Integrated care service models extend along a continuum from coordinated (simple information sharing), to colocated (both services delivered at one location), to integrated (medical and behavioral health care components in one treatment plan) care.¹¹

As the potential benefit for integrated HIV-SA treatment is recognized, the number of integrated treatments is growing. In a review of HIV integrated care programs published through October 2003, Soto et al.¹² described three HIV-SA integrated interventions: provision of SA treatment paired with ancillary services,¹³ combined SA and mental health services,¹⁴ and reminders for HIV caregivers to assess for SA.¹⁵ More recent HIV-SA interventions have included case management provided by HIV-positive paraprofessionals who formerly used substances,¹⁶ combined counseling and structured housing (Project LIGHT¹⁷), and the Rural HIV/AIDS, Substance Abuse, Mental Health Cost Study (COST) study. The COST study combined weekly individual and group therapy with regular communication between behavioral health providers (BHPs) and medical providers for people with HIV, SA, and mental illness.¹⁸ Outcomes included decreased substance use, psychiatric symptoms, hospitalizations, and emergency department usage.¹⁹ Participants also were more likely to be receiving antiretroviral medications and adequate psychotropic medication regimens at follow-up.

Implementation science focuses on the study of moving empirically-based treatments into routine use, and includes the study of effective health care approaches and their translation into clinical guidelines.²⁰ In the case of integrated care treatments, implementation can affect the degree to which the treatment is integrated. Specific practice components for HIV-SA treatment integration and the adaptations necessary for implementation in a variety of settings have not been defined, and recommendations for implementation of integrated HIV-SA models are lacking. Furthermore, the impact of the degree of HIV-SA treatment integration from the providers' perspective is not well understood. In this article, we examine adaptations to the COST HIV-SA integrated intervention at multiple sites in a follow-up study called Expansion to: identify adaptations made; understand how the adaptations impacted the degree of integration; clarify the pros and cons of more- versus less-integrated treatment from the providers' perspective; and develop an initial set of recommendations for the integration of HIV and SA care.

Methods

The integrated treatment intervention

The COST treatment model, initially for patients triply diagnosed with HIV, SA, and mental illness, includes collaborative communication between medical providers and licensed clinical social workers (BHPs), who provide integrated SA treatment. Using the Transtheoretical Model of behavior change,²¹ the BHP identifies the patient's readiness for SA treatment and HIV care. Motivational interviewing²² through individual counseling is used to enhance patients' motivation for change and set individual goals while immediate subsistence needs are assessed and addressed. Individual and group therapy are used to assist patients with coping skills, social support, engagement in healthy activities, grief and loss issues, and relapse prevention. Throughout treatment, psychiatric assessments are made available to patients. Additional model details are described elsewhere.¹⁸ The integrated treatments that were adapted from the COST study were intended to mirror the treatment of the COST study, with two important differences. In the COST study, BHPs provided substance use treatment in a location away from the ID clinics. Individuals sites could alter the intervention to fit the needs of their clinics and populations. Alterations were decided upon at the site level, with collaboration occurring across sites at quarterly meetings.

Study design and participants

The Expansion Project is an implementation study of the COST intervention. The COST intervention was adapted for usual care conditions in three HIV clinics in central North Carolina. This adaptation began in September 28 2002, and with funding from SAMHSA (TI# TI14386) continued through September 29 2008. Table 1 provides contextual details on the size, staff, and patient demographics for each clinic. Site 1 was a large academic infectious disease clinic located in a small urban area, drawing some rural patients (urban–rural mix). Site 2 was a small community health center HIV clinic located in a health department in the same small urban area as site 1. Site 3 was an infectious diseases clinic located in a smaller population center, drawing many rural patients (rural–urban mix).

Table 1.

Site Characteristics

Characteristics	Site 1: Academic; urban-rural mix		Site 2: Community Health Center		Site 3: Academic; rural-urban mix
Orientation	Academic		Community Health Center		Academic
No. HIV pts seen/yr	1570		321		1372
No. of medical providers on staff	16 Attending MDs (2.1 FTE)		1.2 FTE (1.0 NP & .2 MD)		12 Attending physicians (1.7 FTE)
	4 ID, 1 Med/Psych Fellows (0.8 FTE)				5 NP (2.5 FTE)
	3 NPs (0.5 FTE)				4 ID Fellows in training (0.4 FTE)
	1 PA (0.2 FTE)
	P/T MDs in OB-GYN, Nephrology, gastrointestinal, endocrinology (0.3 FTE)
No. other support staff in clinic	2 CMAs		1 LPN nurse (1.0 FTE)		1 Social worker
	1 CNA		1 Receptionist (1.0 FTE)		1 Finan. counselor
	1 RN		1 Case worker-finan. couns.(1.0 FTE)		1 Assistants
	1 Mental health couns.		1 Community educator (1.0 FTE)		2 Admin. assistants
	2 Patient service associates		1 Case manager (0.6 FTE)		3 Nurses—(1 RN, 1 LPN, 1 RA)
	1 Financial counselor
	1 Medical clinic coordinator
	2 Social workers
	1 Pharmacist
	1 Pharmacy tech
African American	58%		87%		59%
White	36%		8%		31%
Hispanic	3%		5%		6%
Native American	2%
Other	1%
Female	30%		32%		32%
Age	Ages	Percent	Ages	Percent	Ages	Percent
	19–29	8%	13–24	4%	13–24	3%
	30–49	66%	25–44	53%	25–44	53%
	50–69	24%	45–64	41%	45–64	42%
	70+	1%	65+	2%	65+	2%
Privately insured	37%		8%		10%
Publicly insured	42%		37%		40%
Uninsured	23%		55%		16%
					Note Unknown = 47%
HIV risk group
MSM	Not available		23%		25%
IDU	Not available		14%		9%
Both MSM & IDU	Not available		2%		1%
Hemophiliac	Not available		1%		1%
Heterosexual	Not available		44%		32% + 13% presumed HTS

ID, infectious disease; NP, nurse practioner; OB-GYN, obstetrics-gynecology; PA, physician assistant; LPN, licensed practical nurse; RN, registered nurse; MSM, men who have sex with men; IDU, injection drug user.

Inclusion criteria for study entry were dual HIV and SA diagnoses. Unlike the COST intervention, the presence of mental illness was not required, due to restrictions from the funder. As shown in Table 2, across sites, the HIV-SA treatment participants consisted predominantly of African American patients without private insurance. Alcohol was the substance most commonly used during the 30 days prior to study enrollment, and cocaine (29.9%) and marijuana use (25.1%) were also reported. The community health center clinic was notable for enrolling higher percentages of uninsured (52%) and recently incarcerated (17%) patients than the academic clinics.

Table 2.

Characteristics of Enrolled Study Participants by Site

Characteristics	Site 1: Academic; urban-rural mix	Site 2: Community Health Center	Site 3: Academic; rural-urban mix
No. enrolled in integrated SA-HIV treatment study	83	91	111
African American (%)	74.6	91.5	73.2
White (%)	19.4	3.7	20.7
Hispanic (%)	3.0	2.4	2.4
Female (%)	49.3	34.2	26.8
Age, mean (SD) and range	44.1 (6.5) 29–61	42.6 (7.0) 26–63	43.1 (7.7) 23–59
Incarcerated in 6 months prior to baseline (%)	6.0	16.5	9.0
Privately insured (% )	10.5	0	9.8
Publicly insured (%)	67.2	45.1	64.6
Uninsured (%)	19.4	52.4	23.2
Using cocaine/crack at baseline (%)	31.3	44.0	51.4
Using alcohol at baseline (%)	53.0	57.1	61.3
Using marijuana at baseline (%)	42.2	34.1	44.1
Using heroin at baseline (%)	19.3	12.1	30.7
Ever IDU (%)	18.1	19.8	26.1

SA, substance abuse; SD, standard deviation; IDU, injection drug use.

Data collection

Beginning in April 2006, qualitative interviews were held with key clinic staff at the three intervention clinics to describe the process by which the COST intervention was adapted for use in three clinics, assess the degree of integration, and examine the advantages and disadvantages of different adaptation strategies. Each of three sites was asked to identify key informants to participate in qualitative interviews. We required that each site include at least one medical provider and one BHP, and allowed sites to include other staff that they deemed essential to their implementation of the integrated model. Four staff per clinic participated in each of the group interviews (n = 12). In addition to medical providers and BHPs, interviewees included clinic managers, medical social workers, a health educator, and a case manager. Interviews were conducted in group format so 1) discrepancies in perception within sites could be resolved during the interview, and 2) qualitative analysis could focus on differences between sites rather than perceived differences within sites. The group interviews were 60–120 minutes long, and both open-ended and close-ended questions were used to elicit information about organizational service structure, types of services provided, location of services, modes of communication used, patterns of communication between medical providers and BHPs, and facilitators/ barriers of integration. This study was approved by the Institutional Review Boards of the two academic sites, and all participants consented to participate per approved procedures.

Analysis

Interviews were audiotaped and transcribed. A summary of the interview responses for each site was created and circulated to the interviewees at that site to ensure accuracy. For each interview question for each site, responses from the summaries were organized into tables to allow for comparison of responses by site. Key project personnel, including project management, medical providers, BHPs, and evaluators developed a consensus description of the differences and similarities in structure and practices across sites.

Results

Degree of integration

Differences in integration structure among clinics were found (Table 3). Site 3 met Blount's¹¹ criteria for an integrated care model, the hallmark of which is a single treatment plan with both medical and behavioral elements. Program characteristics that often lead to a single integrated treatment plan are: (1) universal screening of the illness and tracking of those patients who screen positive; (2) shared protocols to address the illness; and (3) a staff member designated to managed the program under the auspices of providers of both disciplines. At site 3, substance use screening was universal. Referral and treatment protocols to address substance use and HIV were in place. In particular, protocols around interdisciplinary team meetings were especially likely to lead to joint treatment plans. The staff member designated to manage the program was a medical provider. Because the BHPs were hired by the medical clinic, there was not in place a hierarchy of BHPs to easily allow for supervision of this staff member by both disciplines, which indicates some degree of emphasis on medical care rather than complete integration. However, with the majority of Blount's integrated criteria met, henceforth, this site will be referred to as the “integrated site.”

Table 3.

Intervention Adaptations by Site

	Colocated model		Integrated model
Characteristics	Site 1: Academic; urban-rural mix	Site 2: Community Health Center	Site 3: Academic; rural-urban mix
No. BHPs on staff	1	1	2
No. BHP hours/week in clinic	30 hours	24 hours	60
	0.75 FTE	0.6 FTE	1.5 FTE
Medical records structure (paper or electronic, separate systems for BHPs and medical providers or same system for BHPs and medical providers)	EMR with medical provider and psychiatric prescription information; BHP notes not included	Medical Providers-mostly paper charting with some EMR recording from 2006 to present; charts include no psychiatric or BHP notes	EMR including psychiatric information and BHP notes
Telephone therapy offered?	No	No	Yes
Group therapy location	Offsite 2 days/wk	Offsite 2 days/wk	Onsite 1 day/wk
Who has access to written BHP records?	BHPs only	BHPs only	All medical providers, anyone working in hospital (i.e., social workers front desk staff )
Do BHPs have access to medical provider records?	Yes	Yes	Yes
Interdisciplinary team mtgs addressing SA treatment?	No	No	Yes
Providers communicate primarily about both SA and medical treatment or just one?	One	One	Both
SA services for ID patients only?	No	No	Yes
Certainty of office space in ID Clinic	Tenuous	Tenuous	Secure
BHPs level of primary affiliation as an addictions provider	High	High	Moderate
Medical providers and BHPs agree on clinical value of SA screening	No	No	Yes
Goal of community outreach efforts	Export SA services to other sites	Export SA services to other sites	Increase referrals to ID Clinic

BHP, behavioral health providers; EMR, electronic medical record; SA, substance abuse; ID, infectious disease.

Blount's¹¹ criteria for a colocalized model are: (1) medical and behavioral health services are provided in the same office suite, sharing front desk staff and waiting space; (2) communication between providers is fostered not necessarily through formal means but through proximity; and (3) there is a referral process between medical and behavioral health providers. At sites 1 and 2, the BHPs reported providing the majority of their individual counseling activities within the ID clinics, which facilitated communication with medical providers. Both medical and behavioral health providers were aware of referral processes to the other discipline. This structure met Blount's criteria for a colocalized model; these sites will be described as colocated sites.

Communication

Clinic size, institutional medical record design, and integration structure were reported to influence communication between the medical and behavioral team members. At the integrated care site, staff reported that exchange of information among BHPs and medical providers occurred through universal consenting procedures and that all staff members were part of a single program. Formal communication occurred via team meetings and shared use of one electronic medical record (EMR) system. Providers indicated easy communication with patients, family, and affiliated care providers about behavioral and medical information, regardless of their area of specialty. Joint use of the EMR by all members of the treatment team was reported to be a core element in integrated service delivery.

At the colocated sites, staff reported that substance abuse treatment was seen as an independent service; therefore, patients signed release of information forms, as needed, to permit communication about patients between different kinds of providers. Communication was reported to occur between individual providers, not in team meetings. In the small co-located site, while communication increased directly with the number of hours a BHP spent in the clinic, informal communication between providers was highlighted as effective. Informal communication was not seen as effective in the large colocated clinic. Staff indicated that, in external communications, providers communicated to others primarily about their areas of specialty (i.e., BHPs communicated about psychiatric, addiction, and social support issues, medical providers communicated about HIV disease status and associated medical issues).

Staff of the colocated clinics said there was no unified charting system in which all providers accessed patient notes. Although BHPs could access medical providers' notes, medical providers could not access BHP notes. CFR 42 Part 2 regulations restrict sharing of substance use treatment information and can be interpreted to limit access of substance use information to medical providers. This interpretation of the CFR 42 Part 2 regulations, combined with the conceptualization of addiction and medical treatments as two separate programs, led to more concerns around the exchange of information than at the integrated site. Medical providers identified that their inability to access BHP notes caused difficulties coordinating treatment plans and understanding the degree of patient's engagement in substance use treatment, medication adherence, and enrollment in substance use treatment. Medical providers indicated frustration at receiving less addiction treatment information than they wanted.

Office space

In both models, providers reported dedicated space was essential to providing services. At the integrated care site, providers reported dedicated space for the BHPs because administrative staff viewed addiction treatment as a core clinic service. Although two BHPs had to share office space, both reported access to clinic interview rooms. At the colocated sites, providers reported that although the office space was not shared, it was more precariously given. For example, one clinic proposed reassigning the BHP's office on short notice with the expectation that the BHP see patients in an administrator's office with the clinic manager present, forgoing confidentiality needs.

Service Delivery

Scope of services

In the integrated model, providers reported that group therapy was provided within the ID clinic, facilitating contact between patients and medical providers. In the colocated model, providers reported that the off-site location of group therapy, offered greater confidentiality to patients since medical providers would be less likely to know the degree of patients' compliance with substance use treatment.

Only the integrated model site offered individual substance use treatment sessions by telephone, not related to the integration model but rather to transportation barriers faced by patients.

Providers reported using food at the integrated site to appease hunger because the population in this clinic was wide-spread and many patients traveled great distances. Nonperishable food (e.g., crackers and juice boxes) was stored out of sight to prevent jealousy among patients not in substance use treatment. The colocated model held group sessions at a site separate from the medical clinics, and providers reported using food as a means of reinforcing life skills, including ordering food, leading prayer before meals, and cleaning up—skills that are often disrupted with addiction.

Substance abuse and mental illness screening

At the integrated site, providers reported increased commitment to universal substance use and mental illness screening, with various clinic resources (social workers, BHPs, students) deployed to assist in screening efforts. BHPs reported that they considered screening to be a core clinical service designed to increase patient access to needed services. At the colocated sites, providers reported that standardized universal screening was not embraced. BHPs considered screening to be an administrative requirement for patients already identified as needing services, while medical providers viewed substance abuse screening as a way of quickly identifying patients who needed a referral and linking patients with that service. At the colocated sites, screening was primarily performed by BHPs.

Community outreach efforts

BHP providers across models reported meeting with community-based organizations to foster collaboration and referrals with the goal of helping PLWHA and SA access the ID clinic for treatment of both disorders. In addition, the BHPs in the two colocated sites were approached by HIV case management organizations to provide substance use treatment to HIV-positive persons onsite at those organizations. Ultimately, BHPs from the colocated sites provided free substance use treatment for PLWHA at those organizations. This service provision was possible because the BHPs at the colocated sites were employed by an addictions practice and not by an ID clinic, enabling them to see PLWHA who were not currently a patient at any ID clinic and link them into medical care.

Professional autonomy

Providers raised differences in the level of professional autonomy BHPs experienced based on the model in which they functioned. At the integrated site, providers reported clear lines of authority throughout the treatment team. They identified a core mission of working to support patients' success in medical care such that the SA treatment was but one core service available to patients to assist them in engaging in and maintaining medical care. All patients at the integrated site had to be engaged in HIV medical treatment, and often when patients kept SA treatment appointments, they were provided with a medical check-in if they also needed medical care or were out of compliance with their medical appointment schedule. At the colocated sites, the medical providers reported little input into the work of BHPs; authority was housed primarily in the psychiatric department from which the BHPs were employed. BHPs reported great independence in professional identity within the treatment team since their services were seen as separate and coordinated with medical treatment but not subordinated to medical treatment. Thus, BHPs in the colocated sites did not have to make the coordination of HIV medical care the first priority, but could instead decide with the client where to place HIV in the priority order of treating multiple morbidities. For example, if the patient was more concerned about his substance use than his HIV treatment, the BHP and patient could begin work on an agreed-upon an initial goal of substance use reduction, and later discuss HIV treatment and its interaction with substance use.

Discussion

All three sites integrated substance abuse treatment into routine HIV medical care, to different degrees based on adaptations. Discussion the degree of integration and other differences identified different strengths of the two practice models. Participants discussed the issues of communication and privacy across a continuum anchored on one side by patient confidentiality and on the other by the need to have strong open communication among all providers to optimize patient health outcomes. Degree of integration and differences in EMR utilization were directly related to each site's chosen point on this continuum.

At the colocated sites, there was a greater premium placed on patient privacy. Neither colocated site communicated through a shared EMR. Legislative mandates represented by federal legislation (i.e., CFR 42 part 2 and HIPPA) were cited as barriers to exchanging patient information for the purpose of integrating care. BHPs determined when to share substance use information with medical providers. There was resistance at both the BHP and organizational levels to modify clinic procedures within the scope of the legislation to facilitate this exchange between treatment teams. At the smaller colocated site, medical providers reported little frustration around accessing substance use treatment information, possibly due to greater in-person accessibility of providers. The other colocated site had a larger and more fragmented medical provider panel, making informal or spontaneous communication more difficult, exacerbating the organization barriers.

At the integrated site, a premium was placed upon open communication across providers, and thus more information was shared across providers. Participation in the HIV-SA treatment program was contingent on a patient's willingness to have multiple care providers share information with each other, with the intent of developing the optimal care plan. Patients who were unwilling to allow this degree of information exchange would not be appropriate for this treatment model. In this site, interdisciplinary communication resulted in a qualitatively different form of communication with patients, family, and ancillary care providers. Providers of both disciplines expressed a greater capacity to speak across both medical and behavioral spheres of patient function. The integrated model structurally developed more intentional opportunities for the exchange of information across disciplines, in the form of shared EMR use, formalized case conferencing and patient panel review.

Standardized universal substance use and mental illness screening was more readily accomplished in the integrated model. Here, hierarchical authority allowed adaptation of the clinic procedures to ensure universal screening through the deployment, assessment, and revision of screening protocols to systematically meet the clinic's administrative and clinical needs. Substance use screening was supported because a standardized SA assessment was deemed necessary for effective HIV treatment. In contrast, at the colocated sites, standardized substance use screening was used conducted primarily with patients requesting provision of SA treatment. Because of the perceived administrative burden of substance use screening, it was implemented slowly, often sporadically, and was marked by a patchwork of staff accepting and declining responsibility for the task.

BHPs had greater logistical support at the integrated site. Despite the scarcity of space at all sites, space for BHP administrative and clinical needs was guaranteed in the integrated clinic. SA treatment was identified as part of the clinic's response to patient needs, and the BHPs were seen as clinic staff. In the colocated sites, space was often in jeopardy and was a constant source of stress. BHPs were not seen as “part of the clinic,” were more vulnerable to the shifting priorities of clinic management, and were required to champion their logistical needs in addition to their clinical responsibilities.

The colocated model offered more opportunities for disciplinary autonomy. Within the integrated model, there was a strong hierarchy in which the BHPs were well respected, yet with needs subordinate to those of the medical providers. Programming decisions were made with approval from medical providers, and ultimate authority for the HIV-SA treatment program rested with the HIV Clinic Medical Director. In the colocated model, neither Clinical Medical Director of either ID clinic assumed authority of the BHPs, allowing a higher level of BHP autonomy around service development and planning.

Colocated BHPs could become a door to medical treatment. Through providing services outside of the HIV clinic, the BHPs had an increased capacity to see clients who were not receiving HIV treatment in ID clinics. The colocated BHPs engaged clients who were reticent to participate in medical care by providing substance use screening and group therapy outside the HIV clinic. Treatment at locations that were external to the medical clinics also increased patient privacy.

In this article, we present the findings from a qualitative substudy the aim of which was to identify key elements that must be addressed while integrating addiction treatment into HIV medical care. We intentionally focused on staff involved in the program implementation to better characterize the implementation experience. The outcomes of the substudy are the themes expressed in the staff interviews. As this is an implementation article, the focus of data collection was to identify differences in program implementation and their perceived advantages and disadvantages., However, preliminary outcome results of the parent study are likely to be of interest here to indicate the program's value and consider the effect of degree of integration on substance use outcomes. Preliminary results indicate that significant reductions in alcohol and drug use were found at the integrated and one colocated site.²⁴ Reductions that were not statistically significant were found at the other colocated site; interestingly, the initial levels of substance use at this site were significantly lower than at the other sites. Overall, these results provide no clear benefit for integrated versus colocated treatment.

There were important limitations to this study. Only staff members most involved with implementation were interviewed, limiting our ability to uncover all potential model advantages and disadvantages. It is also possible that the group interview process may have inhibited the honest disclosure of all issues, particularly for the integrated site in which the BHPs were supervised by medical providers present in the interview. However, BHPs at this site were vocal during the cross-site data interpretation process, and mentioned disadvantages as well as advantages.

Another limitation to this study lies within the diversity of the three clinics, and the fact that many characteristics of the clinical settings were not the result of colocated versus integrated treatment. However, as we looked at the realms to study for this paper, we intentionally selected areas that all three clinics identified as significant for comparison. Interviews were drafted and conducted in year 3 of the project, and were interpreted by representatives of all clinical sites ensure that the results described accurately the key qualities present in the integration process at all three sites. As the growing body of literature clarifies the benefits of addiction treatment in HIV care, through engagement and retention in care,^25,26 as well as in improved health outcomes, understanding the process of adaptation and replication of models in different clinical settings becomes crucial. The key elements of integration revealed in our interviews enable us to make recommendations for implementing integrated HIV-SA programs.

Prior to implementation of an integrated HIV-SA treatment program, a review should be conducted that addresses these key issues:
• Determine the role of substance use screening within the practice and develop screening and referral procedures.

• Determine the desirable balance between provider communication and patient privacy based on structural elements in the practice, such as EMRs, provider belief systems, and legal constraints.

• Consider care of patients not engaged in HIV medical care and develop administrative structures to provide outreach to them.

• Determine the source of supervision, oversight, and limits of professional autonomy for BHPs.

• Assess organizational readiness to implement the integrated model.²³

• Work with administrators to ensure continued BHP access to office space appropriate for conducting individual and group therapy.

Footnotes

Acknowledgments

This work was supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) HIV/TCE grant number 6H79TI14386. We thank Gabriel Griffin, Douglas Thomas, Genevieve Ankeny, Melissa Green, and Daysha Lawrence for their help in conducting, transcribing, and summarizing interviews. We thank Janet Scovil and Stephanie Bouis for thoughtful comments on differences between models. We thank the staff for their time and insightfulness in participating in the interviews. We thank Ashwin Patkar, Sandra Gomez, Randall Pollard, Susan Reif, Kathleen Sikkema, and Amy Heine for comments on this manuscript. Finally, we want to acknowledge the support of Kathryn Whetten, as mentor, guide, and advisor in the development of this manuscript and the adapted treatment model upon which it is based.

Author Disclosure Statement

No competing financial interests exist.

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