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: bridget.murphy.home@gmail.com
445
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B. S. MURPHY ET AL.
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
HIV EVIDENCE-BASED MODELS FOR ADOLESCENTS
447
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
✓
✓
—
—
—
✓
✓
—
Godley et al. (2001)
Godley et al. (2006)
Fisher & Fisher (1992)
Select Media (1992)
✓
—
✓
Sample & Kadden (2001)
—
✓
✓
—
✓
—
—
✓
✓
—
✓
✓
Bloom (1994)
Najavits (2007)
Greene et al. (2011)
Kamb et al. (1998)
Rawson et al. (2005)
Source
✓
✓
✓
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
HIV EVIDENCE-BASED MODELS FOR ADOLESCENTS
449
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.
HIV EVIDENCE-BASED MODELS FOR ADOLESCENTS
451
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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B. S. MURPHY ET AL.
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.
HIV EVIDENCE-BASED MODELS FOR ADOLESCENTS
453
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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B. S. MURPHY ET AL.
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
HIV EVIDENCE-BASED MODELS FOR ADOLESCENTS
455
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
456
B. S. MURPHY ET AL.
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.
HIV EVIDENCE-BASED MODELS FOR ADOLESCENTS
457
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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