Computerized Substance Use and Depression Screening and Behavioral Treatment in HIV Primary Care

Substance use disorders (SUDs), anxiety and depression are common among HIV-positive patients
and lead to poor HIV treatment outcomes and increased mortality. Yet these disorders often go
unrecognized and untreated, despite the availability of effective interventions. To enhance
HIV care, this study examines the impact of self-administered tablet-based screening for SUD
risk, anxiety and depression using validated measures, with results integrated into the
electronic health record and reviewed by behavioral health specialists (BHSs) embedded in
primary care HIV clinics. Based on screening results, BHSs will initiate motivational
interviewing (MI)- and cognitive behavioral therapy (CBT)-based clinical interventions. Using
a hybrid study approach, the investigators will evaluate both implementation and
effectiveness of screening and intervention. Specifically, the investigators will employ a
stepped-wedge trial design, with a 12-month intervention phase implemented sequentially in
the 3 largest HIV primary care clinics serving 5000 HIV-positive patients in Kaiser
Permanente Northern California (KPNC), with a 12-month usual care period prior to
implementation in each clinic functioning as an observational phase for comparison. This
design, a variation of a cross-over RCT, allows for intervention refinement at each clinic
and provides the opportunity to compare outcomes among patients before and after
implementation. The investigators will evaluate patient-level (e.g., demographics, HIV, SUD,
anxiety and depression severity) and provider-level (e.g., provider attitudes) factors
affecting implementation and effectiveness, and will analyze cost effectiveness. The results
of the study will provide insights regarding the implementation of evidence-based treatments
for SUD, anxiety and depression, such as: 1) How self-administered computerized SUD, anxiety
and depression screening and corresponding behavioral interventions can be effectively and
efficiently implemented in HIV primary care clinics and sustained over time; 2) What patient
and clinic characteristics influence screening and intervention rates; 3) To what extent
implementation of screening and treatment impacts SUD and depression outcomes, as well as HIV
outcomes, including retention in care, viral suppression and Veterans Aging Cohort Study
index score, and 4) What are the barriers, facilitators and costs of implementation. The
study setting is generalizable to other HIV clinics and health systems and will provide key
data regarding the effective delivery of treatment options within primary care settings, and
in coordination with SUD and psychiatry specialty care. Furthermore, the study addresses
NIH-identified high priority HIV research topics since effective treatment of SUDs and/or
depression anxiety would alleviate HIV treatment disparities for these individuals and reduce
SUD-, anxiety and depression-related medical comorbidity and mortality.

Inclusion Criteria:

- HIV-positive adults

Exclusion Criteria:

- Patients under age 18