Screening, Brief Intervention, and Referral to Treatment (SBIRT): E2i

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is designed to screen clients for drug and alcohol use, educate clients on the risks of use, and connect them to substance use treatment services if necessary. SBIRT is an evidence-informed intervention that has been adapted by HIV experts in collaboration with community members to improve health outcomes among people with HIV. Two sites implemented SBIRT as part of Using Evidence-Informed Interventions to Improve Health Outcomes among People Living with HIV (E2i), an initiative funded by the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program from 2017–2021. Among the clients enrolled in SBIRT, the percentage with a prescription of antiretroviral therapy (ART) and who reached viral suppression both increased significantly.

Wilton Manors, FL

Newark, NJ

Evidence-Informed Intervention
Clinical service delivery model
Retention in HIV medical care; Prescription of antiretroviral therapy; Viral suppression
Treat
All clients
RWHAP SPNS
RWHAP-funded clinic or organization
Need Addressed

Many people with HIV struggle with risky or dependent substance use. Risky substance use is associated with a number of adverse effects for people with HIV, including reduced adherence to medication, increased viral replication, and more rapid disease progression.1,2 The use of SBIRT has been shown to improve outcomes for people with HIV, including reduction of alcohol and drug use six months after receiving an intervention, improved quality of life (e.g., employment, education, housing stability, and arrest rates), and reduced risky behaviors (e.g., condomless sex).3,4 The syndemic nature of substance use disorder and HIV has led to recommendations to integrate substance use screening and treatment into RWHAP-funded service settings and other community-based AIDS service organizations.5

“Because alcohol and drug use can affect your health, including your viral load, we ask all clients about their use of alcohol and other drugs.”

Core Elements
Universal screening

As part of SBIRT, all clients are screened for drug and alcohol use on a regular basis, often alongside other routine screenings such as mental health. Universal screening helps normalize the process so clients do not feel singled out, and can help quickly assess the presence and severity of drug or alcohol use. Clients may prefer to answer screening questions in different formats, such as paper or electronic forms on tablets, while others may want to be asked the questions verbally. 

It is important for SBIRT providers to establish rapport with their clients, even if this takes time. It may be helpful to ask the client’s permission to ask about substance use, to explain why certain questions are being asked, and assure the client that information is kept confidential in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

If clients report drug use for non-medical reasons, or alcohol use above recommended limits, they should be screened further using a validated screening tool such as AUDIT-C or DAST. The results of these screenings will determine the next steps in the intervention. 

Brief intervention

Interventions are tailored to the client’s needs based on the results of their drug and alcohol screening.

  • Clients reporting low-risk alcohol use—or no drug use—receive positive reinforcement. The most impactful reinforcement occurs when clients state aloud their own reasons for not using drugs or alcohol. It can be beneficial to affirm the clients’ choices and ask what helps them maintain healthy behaviors. This can also be an opportunity to provide education and explore strategies to continue healthy behavior, particularly among clients who are in recovery for drug or alcohol use.
  • Clients who report moderate or severe substance use should immediately receive a brief intervention, if feasible. As the name implies, this should be a short conversation conducted in 10 minutes or less. The aim of the intervention is to increase clients’ awareness of their substance use and to set the stage for behavioral change. The conversation uses motivational interviewing techniques and should be client-led. It is intended to motivate clients and help them identify their own reasons for change, rather than simply giving them information and instructions.
  • Regardless of their readiness to engage in substance use treatment, clients who report substance use may benefit from additional therapy sessions with a behavioral health specialist.
Referral to treatment

Clients who report high-risk drug and/or alcohol use should receive a timely and carefully coordinated referral to substance use treatment. The level and type of care must be tailored to the client’s needs and decisions should be collaborative, involving the client. This will help increase the likelihood of success by ensuring the client is confident and ready to engage in treatment. Based on the client’s needs, treatment may include inpatient or outpatient services, detoxification, or medication-assisted therapy (MAT).

Many clients will not be ready to engage in treatment, particularly the first time it is offered. It is important to honor the client’s decision and ask permission to bring up the conversation again at future encounters. Continued engagement in HIV clinical care and other supportive services is critical to keep the conversation going and allows for regular check-ins with the client. Even in the absence of substance use treatment, small steps toward recognizing and addressing substance use should be celebrated and affirmed with the client at every opportunity.

Outcomes

Over a 14-month period, the two E2i sites conducted SBIRT screening with 943 clients with HIV. The E2i initiative measured HIV care continuum outcomes at the time of enrollment and 12 months later. Among the clients enrolled in SBIRT, the percentage with a prescription of ART and who reached viral suppression increased significantly. Engagement and retention in care rates also improved, although at non-significant levels.

Category Information
Evaluation data Client medical data
Measures Engagement in HIV care, retention in HIV care, receipt of ART, viral suppression
Results
  • Engagement in care improved from 86% to 88%
  • Clients on ART increased from 92% to 99%*
  • Retention in care improved from 66% to 67%
  • Viral suppression increased from 76% to 91%*

*statistically significant 

Source: Screening, Brief Intervention, and Referral to Treatment (SBIRT): E2i Implementation Guide. Rockville, MD. U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau; 2021.

“With SBIRT, we have seen clients go from homelessness and addiction, to becoming sober, getting housing and their GED, and decreasing their viral load.”

Planning & Implementation

Setting and initial plan

SBIRT can be implemented in a variety of medical and non-medical settings where people with HIV receive services. For example, for the E2i initiative, a food pantry and an HIV primary care clinic implemented SBIRT. Regardless of the setting, it is important to develop an implementation plan for each component of SBIRT. Staff should identify:

  • Which clients will be screened
  • How often clients will be screened
  • Who will screen clients and where
  • How SBIRT activities will be documented
  • Who will provide brief interventions
  • Who will ultimately diagnose the client and make referrals for treatment
  • How to follow up with clients

Staffing

There are different approaches that organizations can take to staff SBIRT services, depending on the preference for a team-based approach or for hiring dedicated SBIRT professionals who conduct the entire process. Regardless of the approach, any staff members conducting SBIRT activities should be adequately trained in SBIRT and motivational interviewing. In a team-based approach, the initial screening tool, along with other screenings, may be handed to the client by the front desk staff for completion in the waiting room. A nurse or medical assistant may conduct a full assessment if required, and the HIV physician may review the screening results with the client and make referrals as appropriate.

Alternatively, a dedicated SBIRT provider may conduct the process from start to finish. This person may be a case manager, social worker, nurse, peer navigator, or any staff member with adequate skills and training. Clients may be more open to discussing substance use with someone other than their case manager or medical provider, particularly if this person is a peer with shared lived experience. Use of a single SBIRT provider may also help ensure consistency of approach across clients and maintain fidelity to the original intervention.  

Referral partnerships

Some RWHAP providers may have the internal resources to provide substance use treatment services onsite. Many HIV clinicians are certified to provide MAT, and thus MAT is integrated into routine HIV care visits. However, many RWHAP providers rely on community-based partners for the provision of substance use treatment. Strong partnerships are crucial to ensure clients receive smooth and effective referrals for treatment. Consideration of how to provide warm handoffs and coordinate services across agencies is important. It is also important that RWHAP staff know what resources are available in their local area, which provide free or sliding fee scale services, and what services are offered at each referral site. The Substance Abuse and Mental Health Services Administration (SAMHSA) provides a treatment services locator to help staff identify resources for their clients. 

“Staff delivering SBIRT services must demonstrate the ability to be empathetic, non-judgmental, and listen reflectively.”

Two sites participated in the SBIRT E2i initiative. Learn more about their implementations below.

North Jersey Community Research Initiative (Newark, NJ)

The Poverello Center, Inc. (Wilton Manors, FL)

Sustainability

SBIRT is a cost-effective and cost-saving approach to addressing substance use6 and can identify alcohol use disorders early, before they become costly.7 Medicare and most commercial insurers cover SBIRT as an alcohol and substance use service; Medicaid, in approximately 25 states, also covers it. For clients without other health care coverage, SBIRT is also an eligible service under the RWHAP funding category of outpatient substance use treatment. 

The costs associated with SBIRT are related to personnel, training, client incentives, and outreach activities that may not be applicable to all implementation sites. See the implementation guide for more information.

“The E2i food pantry site reported that clients experienced insurance coverage barriers to accessing substance use disorder treatment. To reduce this barrier, the site would check with agencies prior to referral to ensure a client’s insurance would be accepted.”

Lessons Learned
  • Incorporate a continuous quality improvement process into your SBIRT program to help it perform consistently and efficiently over time. This should include feedback from SBIRT staff and clients, incorporating incremental improvements, and learning from—and sharing—successes with other SBIRT programs in your region. 
  • Incorporate initial SBIRT screening questions into existing screenings. Two or three questions is typically enough to determine drug use or problematic alcohol use initially. Embedding these questions among other screening questions reduces burden on the clients and providers, but also normalizes substance use screening. This approach may be effective when combining substance use and mental health screenings, since many people with HIV have comorbid mental health and substance use conditions that can be identified and treated simultaneously. 
  • Establish and nurture collaborations with community partners. Most RWHAP providers will rely on partnerships to provide at least some, or perhaps all, substance use treatment services. Solid partnerships will help ensure timely and effective referrals for clients. It is also important to develop robust referral tracking mechanisms that help monitor client progress and facilitate follow-up. 
  • Provide training on substance use, stigma, cultural humility, and implicit bias to help mitigate discomfort around discussions of drug and alcohol use. All staff, including clinicians can benefit from these trainings, even those not involved in SBIRT services. 

“It’s rewarding to not just assist people with food and housing, but also to understand each one of them. Here is the place where our clients know that they won’t be judged. They tell us things they won’t tell a therapist.”

Contact
North Jersey Community Research Initiative (NJCRI)
The Poverello Center
References
  1. Kalichman SC, Grebler T, Amaral CM, et al. Intentional non-adherence to medications among HIV positive alcohol drinkers: prospective study of interactive toxicity beliefs. J Gen Intern Med. 2013;28(3):399-405.
  2. Volkow ND, Montaner J. The urgency of providing comprehensive and integrated treatment for substance abusers with HIV. Health Aff (Millwood). 2011;30(8):1411-1419.
  3. Satre DD, Leibowitz AS, Leyden W, et al. Interventions to reduce unhealthy alcohol use among primary care patients with HIV: The health and motivation randomized clinical trial. J Gen Intern Med. 2019;34(10):2054-2061.
  4. Dawson-Rose C, Draughon JE, Cuca Y, et al. Changes in specific substance involvement scores among SBIRT recipients in an HIV primary care setting. Addict Sci Clin Pract. 2017;12(1):34.
  5. Garner BR, Gotham HJ, Knudsen HK, et al. The prevalence and negative Impacts of substance use disorders among people with HIV in the United States: A real-Time Delphi survey of key stakeholders. AIDS Behav. 2022;26(4):1183–196.
  6. Barbosa C, Cowell A, Bray J, Aldridge A. The cost-effectiveness of alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) in emergency and outpatient medical settings. J Subst Abuse Treat. 2015;53:1–8.
  7. Barbosa C, Cowell A, Dowd W, Landwehr J, Aldridge A, Bray J. The cost-effectiveness of brief intervention versus brief treatment of Screening, Brief Intervention and Referral to Treatment (SBIRT) in the United States: Cost-effectiveness analysis of SBIRT. Addiction. 2017;112:73–81.

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