Integrating Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care

Three participating clinics—MetroHealth, the University of Kentucky Bluegrass Care Clinic, and Centro Ararat—participated in a Ryan White HIV/AIDS Program Part F Special Projects of National Significance (SPNS) initiative from 2016 through 2019 to implement integrated buprenorphine treatment and HIV care. Research has shown that care integration improves HIV outcomes, engagement in substance use disorder (SUD) treatment, and quality of life for people with HIV. Clients participating in this intervention received integrated opioid use disorder (OUD) and HIV care to improve retention in care, viral suppression, and engagement in OUD treatment.

Cleveland, OH

Lexington, KY

Ponce, PR

Evidence-Informed Intervention
Icon for Intervention Type
Clinical service delivery model
Icon for HIV Care Continuum
Linkage to HIV medical care; Retention in HIV medical care; Viral suppression
Icon for Ending the HIV Epidemic in the U.S. Pillar
Treat
Icon for Focus Population
People with opioid use disorder
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RWHAP Part F SPNS
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University-based clinic; Hospital or hospital-based clinic
Need Addressed

People with untreated OUD often struggle with engagement in HIV care and with HIV medication adherence.1 People who are in treatment for both OUD and HIV may receive fragmented care and inconsistent clinical visits, and can benefit from integration of OUD treatment with HIV care.2,3Buprenorphine Treatment for OUD in HIV Primary Care is an evidence-informed intervention developed by HIV experts in collaboration with community members to improve health outcomes among people with HIV and OUD. In this intervention, clients receive treatment for OUD and HIV in a single setting, with the goals of reducing opioid use and overdose while improving client engagement in HIV care.

Core Elements
Enhanced staffing

Implementation sites used clinical coordinators who were responsible for ongoing client support and managing the intervention flow (e.g., conducting client assessments and coordinating appointments). This role was distinct from, but complemented, HIV case management. Additionally, sites worked with clinicians so they could prescribe both buprenorphine and HIV medication. All staff, including front desk staff, participated in trainings to better understand the intervention and how to best serve people with OUD.

Developing plans with the client

Once clients were identified and assessed for participation in the intervention, a staff member (often the clinical coordinator) worked with the client to develop a treatment agreement, recovery plan, treatment plan, and timeline. Clients were also given educational materials and counseled on what to expect from treatment. Based on preference and previous experiences, clients began treatment in the office or at home.

Stabilization visits

For about two weeks, clients’ treatment was monitored daily (for unstable clients) to once a week. This included both medical intervention, including adjustment of the buprenorphine dose, and checking in with coordinators for support and medication reminders for buprenorphine and HIV medications.  

Ongoing monitoring and medication management visits

Clients continued to come in for regular visits until they demonstrated significant reduction in or abstinence from substance use. Monitoring visits included counseling and assessments (e.g., urine testing) and medication management visits were specific to clinical aspects of treatment. Both types of visits were weekly or monthly based on client needs.

Linkages to additional services

Clients were connected to counseling and recovery support services in addition to medication-assisted treatment. All clients were assessed for counseling needs. Clients were also referred to more intensive services if needed.

Outcomes

Across the three demonstration sites, a total of 94 clients received services through this intervention.

Category Information
Measures

Number of clients who:

  • Were linked to care within 90 days
  • Were retained in care (had 2 medical appointments at least 90 days apart in 12 months)
  • Were virally suppressed at 12 months after enrollment
Results
  • 64 (68%) of clients were linked to care
  • 60 (64%) of clients were retained in care
  • 53 (56%) of clients were virally suppressed

Source: Dissemination of Evidence-Informed Interventions. Integrating Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care (2020).

Planning & Implementation

Clinician training. HIV clinicians were trained to prescribe buprenorphine effectively and to provide culturally responsive care when serving people with OUD.

Review of applicable laws. Before implementation, clinics reviewed federal, state, and local laws and regulations to see what services were allowable in their jurisdictions. For example, some states have more restrictive rules around prescribing buprenorphine, including regulations around sharing client data.

Visit structure and work flows. The exact timing and structure of initial and follow-up visits depended on current capabilities as well as a client’s needs. Before implementing visits, the treatment team developed a communication plan for meeting and discussing clients and program flow regularly.

Specialized program materials. Staff created resources, checklists, and other materials that made sense for their program. They also tailored educational materials to their client population and created “kick packs” to help clients through the initial stages of the intervention, including how to manage the symptoms of opioid withdrawal.

Community partnerships. Staff assessed the existing opportunities in their communities for medication for OUD, substance use disorder treatment, and wraparound services, and built partnerships with provider agencies and programs to ensure that their clients had access to comprehensive care.

Technical assistance. Activities were supported by the Dissemination of Evidence Informed Interventions (DEII) dissemination and evaluation center and the DEII technical assistance center.

“Getting buy-in from clinic staff was the single most important thing we did to effectively implement this program. Buy-in may come slowly and may require staff to see firsthand the changes that addiction treatment makes in patients’ lives.”

Sustainability
  • Outpatient substance use treatment can be provided with RWHAP funds. Additional providers can be added to the intervention as client participation grows. Meeting with administration twice a year to discuss needs, budget, and outcomes can be effective in facilitating integration and improving sustainability.
Lessons Learned
  • A large amount of effort was required for staff to contact clients at the start of treatment; however this does benefit relationships and less effort is needed over time.
  • Many clients relapsed or fell out of care during the intervention; relapse is expected during the substance use recovery process. It is important to meet clients where they are and to welcome them back into treatment without judgment.
  • Some clients who were eligible for participation in this intervention had co-occurring needs, such as polysubstance use and mental health conditions, which required intensive engagement. Pacing enrollments and creating alternate clinic schedules helped staff even out and sustain their caseloads.
  • This intervention was a team effort and all staff—from front desk workers to clinicians—needed to be actively involved for success. It is important to engage staff in trainings and highlight the benefits that medications for opioid use disorder have on client health.
  • Community partnerships were necessary for referring clients who needed a higher level of care.
  • Prior authorizations can be cumbersome and time-consuming. Developing relationships between the clinical coordinators and pharmacies/insurance administrators helped staff navigate challenges and to speed up the authorization process.

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