Integrating Buprenorphine Into the SFGH AIDS Program

The UCSF Positive Health Program (formerly called the AIDS Program) at San Francisco General Hospital (SFGH) is one of the oldest and largest HIV/AIDS clinics in the United States. Located at the public hospital serving medically indigent residents of San Francisco, the Positive Health Program (PHP) provides over 2,000 patient visits per month to 2,300 patients in a comprehensive HIV primary care setting. The clinic population is disproportionately affected by heroin and other opiate abuse problems. Opiate replacement therapy (ORT) has a stabilizing effect in HIV-infected injecting drug users (IDU) and is associated with greater acceptance of antiretroviral (ARV) therapy, higher ARV adherence, and greater engagement in appropriate HIV-related health care. However, there are insufficient resources to meet the critical substance abuse treatment needs among our opioid-dependent patients.

In partnership with the Community Behavioral Health Services (CBHS) section of the San Francisco Department of Public Health (SFDPH), the UCSF Positive Health Program (PHP) at San Francisco General Hospital (SFGH) has developed a model of care, which provides opioid-dependent patients with integrated, office-based buprenorphine ORT in the HIV primary care setting. The program also offers primary care providers with education and training on addiction, opiate addiction treatment, and the appropriate use of buprenorphine. An evaluation of the program is planned to examine: (1) its effects on the health and substance use of patients; (2) program costs; and (3) what broader impact the program has on providers, institutions, and local systems. In the patient evaluation study, eligible, opioid-dependent patients that receive primary HIV care at the PHP will be randomly assigned to receive buprenorphine ORT for twelve months either in the integrated HIV primary care setting (intervention group) versus a non-integrated substance abuse treatment clinic setting (comparison group). Data will be abstracted from medical chart reviews and will be collected from patients using standardized instruments and satisfaction surveys.

Inclusion criteria

• Age > 18 years
• Fluent in English
• Receive HIV primary care at the UCSF Positive Health Program
• Meet DSM-IVR criteria for opioid dependence
• Meet clinical criteria for buprenorphine treatment (see Exclusion Criteria)
• Plan to stay in the San Francisco Bay Area for the next 12 months

Exclusion criteria

• Severe hepatic dysfunction, i.e., AST and/or ALT > 5X upper limit of normal
• DSM-IV criteria for benzodiazepine abuse or dependence within the past 6 months
• DSM-IV criteria for alcohol dependence within the past 6 months
• Actively suicidal
• Psychiatric impairment that impedes ability to consent (dementia, delusional, actively psychotic)
• Methadone or opiate analgesic doses exceed level allowing for safe transition to buprenorphine
• Pregnant women and women actively trying to become pregnant

Potential subjects also will be excluded for:

• Any medical condition(s), which, in the opinion of the investigator, would interfere with the patient's ability to participate in or adhere to the requirements of this study
• Unable or who decline to provide informed consent for the evaluation