Determinants of the Availability of Hepatitis C Testing Services in Opioid Treatment Programs: Results From a National Study

Objectives. We examined trends and organizational-level correlates of the availability of HCV testing in opioid treatment programs.Methods. We used generalized ordered logit models to examine associations between organizational characteristics of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey and HCV testing availability.Results. Between 2005 and 2011, the proportion of opioid treatment programs offering HCV testing increased but largely because of increases in off-site referrals rather than on-site testing. HCV testing availability was higher in opioid treatment programs affiliated with a hospital and those receiving federal funds. Opioid treatment programs providing both methadone and buprenorphine were more likely to offer any HCV testing, whereas opioid treatment programs providing only buprenorphine treatment were less likely to offer on-site testing. HCV testing availability was associated with more favorable staff-to-client ratios.Conclusions. The increasing use of off-site referrals for HCV testing in opioid treatment programs likely limits opportunities for case finding, prevention, and treatment. Declines in federal funding for opioid treatment programs may be a key determinant of the availability of HCV testing in opioid treatment programs.HCV is the most common blood-borne infection in the United States. An estimated 3.2 million people in the United States are chronically infected with HCV,1 making it 3 to 5 times more frequent than HIV.2 Results from a recent study showed that HCV has surpassed HIV as a cause of death in the United States.3 New HCV treatment regimens that are more effective and have fewer side effects have recently become available.4 Unfortunately, fewer than half of the patients living with HCV are aware of their infection.5 This is because infected persons tend to be asymptomatic: in some cases, signs of the disease do not manifest for decades.6 It is thus important to encourage and offer extensive opportunities for HCV testing, especially to the most at-risk populations.6Advancements in testing technologies (HCV rapid testing)7 and recommendations for the identification of HCV in the general population (i.e., individuals born between 1945 and 1965) present opportunities for increasing the availability of HCV testing.8 Testing could foster increased case finding, as well as earlier linkages to HCV care and treatment services. Ensuring access to HCV testing and increasing awareness of HCV status also could help promote the adoption of preventive behaviors: for example, engaging in safer injection practices or other protective behaviors. Ultimately, this may also have a positive influence on compliance with substance abuse treatment and abstinence.9The Centers for Disease Control and Prevention (CDC) recommends routine HCV antibody (anti-HCV) testing for injection drug users (IDUs).3,10 IDUs are particularly at risk for HCV infection as a result of sharing and reusing of needles or other injection paraphernalia.6 The estimated anti-HCV prevalence among IDUs ranges from 35% to 65%, depending on factors such as geography and rate of injection drug use.11 Unfortunately, despite the CDC recommendation, IDUs have very low rates of uptake for HCV testing and treatment.12One factor that may account for such low testing rates is that IDUs less frequently use preventive health care services than do other population groups.13 Outpatient substance abuse treatment programs are one exception: the number of IDUs entering treatment programs has increased in recent years.14 Because injection drug use is strongly associated with opioid use (e.g., heroin), opioid treatment programs are an especially important setting for HCV testing, counseling, prevention, and links to medical care. In the case of HIV testing and case management, on-site services in substance abuse treatment programs have been associated with high-quality prevention, increased service use, earlier initiation of treatment, declines in disease transmission, improved treatment outcomes for substance use disorders, and links to ancillary services.15–17 Hence integrating HCV testing with substance abuse treatment services, particularly in opioid treatment programs, may have similar beneficial effects and is crucial for addressing the HCV epidemic in the United States.18Unfortunately, trends in the availability of HCV testing services in opioid treatment programs across the nation are not well understood.19,20 Large gaps exist in the availability of on-site HCV testing in opioid treatment programs,21–24 with programs that have the largest proportion of IDUs among their clients being less likely to offer on-site HCV testing, even when phlebotomists were on staff.24 Opioid treatment programs often prefer to refer their clients to off-site facilities for HCV testing. Yet off-site referrals for testing and treatment of HCV are associated with significant reductions in the uptake of these services.25There is also an urgent need to examine the organizational-level characteristics of treatment programs that may serve as facilitators or barriers to the availability of HCV testing services, either on-site or off-site, in the nation’s opioid treatment programs.26 HCV testing services may not be offered in opioid treatment programs in the United States for several potential reasons. First, opioid treatment programs may lack the required financial resources, including reimbursement and funding, to implement testing services.23,27–29 Second, treatment programs may not have the human resource capacity (e.g., low staff-to-client ratio) to effectively offer both substance abuse treatment services and ancillary services. Similarly, the ownership and affiliations of opioid treatment programs may influence the extent to which they can offer HCV testing services. For example, publicly owned opioid treatment programs might be more likely to have a prevention-driven mission, whereas hospital-affiliated opioid treatment programs may have access to networks that enable them to provide HCV testing services. Organizational-level predictors for HIV testing services in drug abuse treatment programs have been examined extensively, but similar national studies for the provision of HCV testing services are scarce.19,30–32We first describe trends in HCV testing availability in the nation’s opioid treatment programs between 2005 and 2011. We then examine the role of organizational factors in promoting the availability of HCV testing services among opioid treatment programs.