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. Author manuscript; available in PMC: 2022 Jun 1.
Published in final edited form as: J Community Health. 2021 Jun;46(3):557–564. doi: 10.1007/s10900-020-00876-y

Dental Care Utilization of Hospitalized Persons Living with HIV and Substance Use

Anthony J Santella 1, Carrigan Parish 2, Rui Duan 3, Daniel J Feaster 4, Allan E Rodriguez 5, Carlos del Rio 6, Wendy S Armstrong 7, Petra Jacobs 8, Lisa R Metsch 9
PMCID: PMC7862424  NIHMSID: NIHMS1654539  PMID: 32761292

Abstract

People living with HIV (PLWH) who use drugs experience worse health outcomes than their non-using counterparts. Little is known about how often they seek dental care and the factors that influence their utilization. PLWH with substance use disorders who were inpatients at 11 urban hospitals (n = 801) participated in a National Institute on Drug Abuse Clinical Trials Network study to improve engagement in HIV outcomes. Dental care utilization at each time point during the study period (baseline, 6 months and/or 12 months) was assessed (n=657). Univariate analysis and logistic regression were used to examine factors associated with dental care utilization. Over half (59.4%) reported not having received any dental care at any timepoint. Participants with less than high school education had lower odds of reporting dental care utilization than those with more than education (aOR = 0.60 [95% CI: 0.37 – 0.99], p=0.0382). Participants without health insurance also had lower odds of reporting dental care utilization than those with insurance (aOR = 0.50 [95% CI: 0.331 – 0.76], p=0.0012). Higher food insecurity was associated with having recent dental care utilization (OR = 1.03 [95% CI: 1.00, 1.05], p=0.0359). Additionally, those from Southern states were less likely to report dental care utilization (aOR=0.55 [95% CI: 0.38, 0.79] p=0.0013). Having health insurance and education are key factors associated with use of dental care for PLWH with substance use disorders. The association between food insecurity and dental care utilization among this population suggests the need for further exploration.

Keywords: dental, HIV, substance use, hospitalization

Introduction

People living with HIV (PLWH) and substance use have sub-optimal HIV outcomes, shorter life expectancies and increased morbidity and mortality compared with persons living with HIV without substance use. 1–3 Lack of medical care engagement is also more prevalent, which is problematic for PLWH who need to remain linked and retained in medical care in order to achieve viral suppression and avoid unnecessary hospitalizations.4 PLWH with HIV-related symptoms and an AIDS diagnosis have a greater need for dental care than those with fewer symptoms and without AIDS, but eclipsing needs for physical and mental health services limit their access to dental care. Access to oral health programs has been shown to improve physical and mental health. In a sample of low-income PLWH, engagement in an oral health program was associated with improvement in overall well-being as measured by change in the Short Form-8 Health Survey.5

People who use drugs and are living with HIV may have higher rates of hospitalization compared to non-drug users.6 There is also evidence that active drug use is associated with HIV disease progression and mortality.7 Effectively targeting and treating active drug use may not only improve HIV-related outcomes, but also oral-systemic related outcomes.

Recent studies have identified barriers to dental care among PLWH, which often lead to postponement of dental care. One study of 2,469 PLWH who had been living with HIV for a decade found that the majority (52.4%) had not seen a dentist in more than two years, almost half (48.2%) reported an unmet oral healthcare need since testing positive for HIV, and 63.2% rated the health of their teeth and gums as “fair” or “poor”. 8 Dental anxiety can also impact dental care utilization specifically among PLWH. One study found that PLWH with severe dental anxiety had 69.3% lower adjusted odds of using oral healthcare services within the past 12 months compared with PLWH with less-than-severe dental anxiety. 9

Additional barriers to dental care have included cumbersome administrative procedures (e.g., access/referral paperwork), long wait times, problem focused care-seeking behavior (i.e., only treating acute dental problems, neglecting preventive oral health care), and negative encounters with dental care professionals. 8 Factors that have previously been identified in facilitating dental care among PLWH (not specific to those with poor HIV outcomes) include coverage for dental care, being treated with respect and acceptance, having an assigned case manager or social worker, resiliency (protection against self-stigma) and reconciliation (i.e., coming to terms with oneself in the face of infection and expecting dental providers to become more knowledgeable about HIV and create a stigmatizing-free environment). 9–10

This paper focuses on the dental care utilization of hospitalized, substance-using PLWH enrolled in a randomized, multi-site study conducted within the National Institute on Drug Abuse Clinical Trials Network (CTN) known as Project HOPE: Hospital as Opportunity for Prevention and Engagement for HIV Infected Drug Users (CTN0049). The primary outcomes of Project HOPE revealed no differences in viral suppression between the three intervention arms (patient navigation vs. patient navigation with contingency management vs. usual care) at the primary 12-month endpoint, six months after the intervention ended. 11 This secondary sub-analysis aimed to assess factors associated with dental care utilization among Project HOPE participants, with a research question focused on understanding the relationship between sociodemographic, HIV care, and risk factors with routine dental care utilization among PLWH with substance use disorders.

Methods

The details of Project HOPE (CTN0049) have been described previously. 10 Project HOPE was conducted at 11 United States (U.S.) hospitals in regions with a high prevalence of inpatients living with HIV and substance use (Atlanta, GA; Baltimore, MD; Birmingham, AL; Boston, MA; Chicago, IL; Dallas, TX; Los Angeles, CA; Miami, FL; New York, NY; Philadelphia and Pittsburgh, PA). The Project HOPE protocol was approved by the institutional review boards at all participating institutions.

Participants were eligible for Project Hope if they: (a) were hospitalized at any study site during recruitment, (b) history of substance use (reported or had documentation of opioid, stimulant, and/or heavy alcohol use within the past 12 months), (c) were at least 18 years old, (d) able to communicate in English, (e) lived near study sites, (f) had minimal functional impairment, (g) authorized a medical record release, (h) provided locator information, (i) were willing to complete the baseline assessment and blood draw, and (j) met at least one of three HIV-related criteria (i.e., had an AIDS-defining illness, had a CD4 cell count <350 cells/uL and a viral load >200 copies/mL within the past 6 months, or had a CD4 count ≤ 500 cells/uL and a viral load > 200 copies/mL within the past 12 months). 12

The main outcome used in this secondary analysis was recent dental care utilization, assessed by the question: “During the past 6 months, did you get any dental care?,” which was asked at three subsequent study time points (baseline, 6 months post baseline, 12 months post-baseline). We then compared two subgroups of participants: (a) participants who had any dental care at baseline, 6 months, and/or 12-months follow-up and (b) participants who had no dental care at baseline, 6 months, or 12-months follow-up. We used these outcome time-points given evidence that at least yearly dental exams provide a health benefit and the endorsement of this measure by the American Dental Association. 13

Several variables were considered as covariates in the analysis. Sociodemographic variables included age, race, sexual identity, educational attainment, employment, income, and whether the CTN study site was in a Southern state (Alabama, Georgia, Florida, Maryland, and Texas). Healthcare-related variables included HIV care, whether dental services were available at the CTN study site, assessed as having an HIV primary care provider, and whether participants had medical insurance coverage. Risk factors included substance use (being a current smoker, alcohol use, and use of opioids and stimulants) and history of incarceration. In addition, the Household Food Insecurity Access Scale (HFIAS) was administered to assess food insecurity. The HFIAS consists of nine items measuring one’s experience with insecure food access, with each item scored on a scale of 0 to 3 where 3 represents the highest frequency of occurrence. The HFIAS score is a sum of the 9 items [range: 0 – 27], indicating the degree of insecure food access. 14 Finally, medical mistrust, defined as the tendency to distrust mainstream health care professionals and health care systems, was included and measured by the Medical Mistrust Scale. This scale consists of 12-items answered via Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The score is a sum of the 12 items [range: 12 – 60], where a higher score indicates a higher degree of medical distrust.15

Statistical Analysis: Characteristics of participants were summarized using proportions for categorical variables and means and standard deviations for continuous ones. Pearson’s chi-square tests were used to assess the bivariate relationship between categorical variables and dental care utilization, and t-tests were used to assess participants’ medical mistrust and food insecurity at baseline to compare the characteristics of participants in the two dental care groups. Logistic regression modeling was used to evaluate the associations between the independent variables and the outcome variable of recent dental care utilization, adjusting for the intervention arm of the trial. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) were reported. Analyses were conducted using SAS statistical software (version 9.4; SAS Institute, Cary, NC). All tests were performed at a significance level of 0.05.

Results

There were 801 participants randomized in the CTN0049 trial who completed a baseline assessment. The majority (n=657) responded to a dental care question at either baseline, 6M or 12M or any combination of these three visits and were included in these analyses. Among these participants who responded to the aforementioned dental care question, almost half were ages 35–49 years old (n= 303, 46.1%) with a median age of 44.5±10.0 years, and almost three-quarters were Black (n=482, 73.7%) (Table 1). About one-third were non-MSM (n=182, 32.4%), almost 40% were female (n=222, 39.6%) and had less than a high school education (n=258, 39.3%). The majority were unemployed/on disability (n=555, 84.5%), and almost two-thirds had health insurance (n= 444, 67.9%). The majority had an annual income less than $20,000 (n=405, 89.2%). Additionally, more than three quarters had been in jail in the past (n= 502, 76.6%). They also reported high rates of being food insecure (mean score, 6.21, SD, 7.89). More than three-quarters were from sites with dental services available (n=528, 80.34%). About half were from Southern states (n=371, 56.5%) (see Table 1).

Table 1.

Report of any dental care utilization at any study time point (baseline, 6 months and/or 12 months) among CTN0049 Study Participants (n= 657), Overall and by Participant Characteristic

Overall
N or mean
(% or SD)		 Any dental care
N or mean
(% or SD)		 No dental care
N or mean
(% or SD)		 p-value
Overall sample 267 (40.6%) 390 (59.4%) N/A
Age (years) 0.861
18–34 139 (21.2%) 54 (20.2%) 85 (21.8%)
35–49 303 (46.1%) 126 (47.2%) 177 (45.4%)
50 or higher 215 (32.7%) 87 (32.6%) 128 (32.8%)
Race (n= 654) 0.003
Hispanic 67 (10.2%) 36 (13.5%) 31 (8.0%)
Black 482 (73.7%) 179 (67.3%) 303 (78.1%)
White 73 (11.2%) 40 (15.0%) 33 (8.5%)
Other 32 (4.9%) 11 (4.1%) 21 (5.4%)
Gender Identity and Sexual Orientation (n= 561) 0.200
Non-MSM 182 (32.4%) 66 (29.0%) 116 (34.8%)
MSM (gay/bisexual men) 157 (28.0%) 72 (31.6%) 85 (25.5%)
Female 222 (39.6%) 90 (39.5%) 132 (39.6%)
Education 0.052
Less than high school 258 (39.3%) 94 (35.2%) 164 (42.1%)
High school 224 (34.1%) 89 (33.3%) 135 (34.6%)
More than high school 175 (26.6%) 84 (31.5%) 91 (23.3%)
Work Status 0.317
Working 81 (12.3%) 27 (10.1%) 54 (13.9%)
Unemployed 238 (36.2%) 106 (39.7%) 132 (33.9%)
Disabled 317 (48.3%) 125 (46.8%) 192 (49.2%)
Other 21 (3.2%) 9 (3.4%) 12 (3.1%)
Insurance Coverage (n= 654) 0.001
Uninsured 210 (32.1%) 63 (23.7%) 147 (37.9%)
Insured 444 (67.9%) 203 (76.3%) 241 (62.1%)
Annual Income (n= 454) 0.285
Less $20,000 405 (89.2%) 158 (87.3%) 247 (90.5%)
$20,000 or higher 49 (10.8%) 23 (12.7%) 26 (9.5%)
Ever in Jail (n= 655) 0.251
No 153 (23.4%) 68 (25.7%) 85 (21.8%)
Yes 502 (76.6%) 197 (74.3%) 305 (78.2%)
Has HIV primary care doctor (n= 656) 0.643
No 101 (15.4%) 39 (14.6%) 62 (15.9%)
Yes 555 (84.6%) 228 (85.4%) 327 (84.1%)
Current Smoker 0.409
No 195 (29.7%) 84 (31.5%) 111 (28.5%)
Yes 462 (70.3%) 183 (68.5%) 279 (71.5%)
Alcohol use at Baseline 0.640
No 263 (40.0%) 104 (39.0%) 159 (40.8%)
Yes 394 (60.0%) 163 (61.0%) 231 (59.2%)
Heroin Use 0.763
No 540 (82.2%) 218 (81.7%) 322 (82.6%)
Yes 117 (17.8%) 49 (18.3%) 68 (17.4%)
Opioid Use 0.083
No 618 (94.1%) 246 (92.1%) 372 (95.4%)
Yes 39 (5.9%) 21 (7.9%) 18 (4.6%)
Stimulant Use 0.353
No 196 (29.8%) 85 (31.8%) 111 (28.5%)
Yes 461 (70.2%) 182 (68.2%) 279 (71.5%)
Medical Mistrust (at Baseline) 28.66 (7.78) 28.28 (8.07) 28.81 (7.76) 0.392
Food Insecurity (at Baseline) 6.21 (7.89) 6.98 (7.98) 5.48 (7.25) 0.014
Dental Service at CTN Site 0.776
No 129(19.6%) 51(19.1%) 78(20.0%)
Yes 528(80.4%) 216(80.9%) 312(80.0%)
CTN Site Location <0.001
Non-Southern 286(43.5%) 144(53.9%) 142(36.4%)
Southern 371(56.5%) 123(46.1%) 248(63.6%)
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Over half (59.4%) of participants reported not having received any dental care at baseline, 6 months, and/or 12 months. Among this group, almost half (45.4%) were 35–49 years old, 78.1% Black, 42.1% had less than a high school education, 62.1% had health insurance, 63.6% were from Southern states and they were largely food insecure (mean score, 5.48, SD, 7.25) (see Table 1).

Bivariate analysis showed that being non-Black (p=0.003), having insurance coverage (p=0.001), higher food insecure score (p=0.014), and being in a Southern state (p<0.001) were statistically associated with higher dental care utilization across subgroups. In assessing the race subgroups, while Blacks represented 73.7% of the overall sample, they also made up 78.1% of those with no dental care at baseline or at 6 and 12-month follow-up (see Table 1).

Logistic regression analysis showed that participants with less than a high school education, compared to participants who completed more than a high school education, were less likely to report dental care utilization (aOR = 0.60 [95% CI: 0.37, 0.97] p=0.0382). Participants without medical insurance coverage were less likely to report dental care utilization (aOR=0.50 [95% CI: 0.331, 0.76] p=0.0012). Participants who had higher food insecurity had greater odds of reporting recent dental care (aOR = 1.03 [95% CI: 1.00, 1.05] p=0.0359). Additionally, those from Southern states were less likely to report dental care utilization (aOR=0.55 [95% CI: 0.38, 0.79] p=0.0013) (see Table 2).

Table 2:

Logistic regression model of reporting any dental care utilization at any study time point (Baseline and/or 6M and/or 12M)

Participant Characteristic Any dental care at any study timepoint
OR (95% CI)		 P value
CTN49 Treatment
Patient Navigation vs. Treatment As Usual 1.07 (0.69, 1.67) 0.7578
Patient Navigation+Incentives vs. Treatment As Usual 0.96 (0.62, 1.48) 0.8451
Age
18–34 years vs. 50+ years 0.82 (0.47, 1.42) 0.4733
35–49 years vs. 50+ years 0.99 (0.64, 1.52) 0.9457
Race
Hispanic vs. White 0.97 (0.44, 2.12) 09292
Black vs. White 0.55 (0.30, 1.01) 0.0552
Other vs. White 0.42 (0.15, 1.24) 0.1158
Gender/ Sexual Orientation
MSM vs. Non-MSM male 1.54 (0.91, 2.61) 0.1062
Female vs. Non-MSM male 1.36 (0.88, 2.11) 0.1689
Education Attainment
Less than High School (HS) vs. More than HS 0.60 (0.37, 0.97) 0.0382
High School vs. More than HS 0.70 (0.43, 1.15) 0.1548
Health Insurance: No vs. Yes 0.50 (0.33, 0.76) 0.0012
Dental Services at CTN Site No vs. Yes 0.82(0.51,1.32) 0.4216
Southern State: Yes vs. No 0.55(0.38, 0.79) 0.0013
Food Insecure Score 1.03 (1.00, 1.05) 0.0359
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Discussion

This paper examines the use of dental care in a study sample of PLWH with poorly controlled HIV infection and substance use disorders, recruited specifically from inpatient hospital settings across the U.S. While HIV has become a chronic and manageable condition, it is important to acknowledge that not all PLWH are achieving optimal health outcomes. In this study, the majority of participants did not receive any dental care at any study time point. This is of concern as preventive dental care is crucial to reduce the occurrence of oral infection and to achieve optimal oral health and well-being. While there is a lack of evidence to claim a causal association between oral infections and other systemic diseases, a large body of evidence suggests that oral infections are a potential contributing factor to systemic diseases such as endocarditis..16–17 This study population represents a sub-group that is not only marginalized and vulnerable but also dealing with several competing medical issues making it important for them to engage in dental care and promoting oral health promotion and management as an investment in overall health.18 Since oral health care has been shown to be a major unmet need for PLWH and programs like Ryan White Part F which provide oral health care for PLWH through the HIV/AIDS Dental Reimbursement Program the Community-Based Dental Partnership Program exist. 19

There has been previous research that has shown that the provision of dental care and medical care is often siloed and this also has been shown to be the case with care for PLWH. 20 Dental providers and the healthcare workforce public health practitioners could contribute to better oral health among PLWH by improving access to both medical and dental care. While previous research showed dental case management interventions can be implemented in HIV clinics to improve linkages to oral health care services among PLWH, additional research is needed to address limitations such as lack of sustainability. 21 Additionally, the Ryan White Part F dental program is not funded at the same levels as medical care which may make it difficult to offer to all PLWH. Since interprofessional hospital teams who manage inpatients often do not include dental providers, additional research and public health planning is needed to identify best practices in linking PLWH to dental and other medical and ancillary services while hospitalized.

We found that lower levels of education were associated with lower odds of using dental care. This is consistent with previous research that demonstrates the importance of education as a primary determinant of health. 22 Attaining higher levels of education is especially important in promoting early hygiene practices and preventive hygiene. 23 Additionally, there is a role for providers and caregivers in oral health education. Positive attitudes have been observed toward incorporation of oral health examination into medical practice, however, oral health training for medical providers is needed in medical education. 24

Similar to another study using CTN0049 trial data that found Southern participants were less likely to experience viral suppression (aOR, 0.52; 95% CI, .37–.72) and had a higher likelihood of a CD4+ count <200 cells/μL (aOR, 1.53; 95% CI, 1.17–2.00) 25 our study found those from Southern states were less likely to report dental care utilization. Additional focus should also be given to addressing this burden in the South which accounts for an estimated 51% of new HIV cases annually even though just 38% of the population lives in the region.26 Social determinants of health such as poverty and unemployment, inadequate access to health insurance, lack of Medicaid expansion (in some states), and cultural factors like stigma and discrimination around gender identity and sexual orientation are driving this epidemic.26 Moreover, in a study of African American MSM, HIV-related stigma was reported as pervasive and a driving factor in lowered participation in HIV testing and treatment. 27 A mix of behavioral and biomedical community-driven and community-placed based interventions to address stigma is needed in the South.

The integration of medical and dental care may also help address this disparity. However, addressing other, more structural and system issues are equally important such as addressing institutional racism, expanding the number of minority dental providers, and ensuring that dental providers are aware of the needs of underserved communities and are willing to meet those needs. 28

Dental insurance coverage, which is separate and different from medical insurance, increases dental care utilization and is associated with better oral health among PLWH. 29 Our study also found that participants without health insurance had lower odds of reporting dental care utilization than those with health insurance. While our study had included almost 60% males, this remains true among female PLWH. In a nationally representative study of female PLWH, all dental insurance types were associated with higher odds of receiving annual dental care. 29 As policymakers continue to debate the value of healthcare reform and the future of HIV-specific payors like the Ryan White program, dental insurance and expanding dental coverage beyond the Ryan White Part F program need to be highlighted.

Findings from a retrospective analysis of National Health and Nutrition Examination Survey data found an association between food insecurity and unmet dental needs, which may be directly due to oral health problems causing trouble with eating. While our results differ, the dental setting represents an often untapped but potentially useful venue in the provision of patient education in the subject of food insecurity. The dental setting can help facilitate patient-provider interactions including, but not limited to, delivering food and nutrition related education and chairside screenings. While dental care and food may both be difficult to access, funds from the Ryan White HIV/AIDS Program may support the provision of oral health services and also food and nutrition services and should continue to be supported. 30–31 Future dental research could also include nutritional assessments and food frequency questionnaires in assessing oral health status.

There are some study limitations to note. First, we only asked about participants’ recent dental utilization. Further studies should include more comprehensive measures including clinical examinations to fully assess the oral health of PLWH. Second, dental care utilization was only measured for the previous six months. While we did assess this measure at three different study time points, it is possible that participants’ dental care utilization during the study was not reflective of their typical frequency of dental care utilization.. Finally, the study instrument asked about health insurance and did not specify dental insurance which is often not the same payor. Since the design and operation of dental benefit and medical insurance plans are functionally not the same, future studies should specifically query about having dental insurance when assessing associations with dental care utilization. 18 Despite these limitations, the key strengths of this study were its recruitment of PLWH across hospitals nationally and the CTN infrastructure that allow for rigorous, multisite clinical studies.

The present study demonstrates that the majority of participants had not seen a dental care provider in the 18 months. This study also demonstrates the importance of social and economic determinants of health and suggests the need for further study to better understand the relationship between food insecurity and use of dental care. Evidence-based interventions that improve access to and retention to dental care programs for PLWH should be developed and advocated for that enable and facilitate access to high quality dental care.

Acknowledgments:

The authors recognize the CTN-0049 participants and staff for their dedication and we show gratitude to CTN-0049 collaborators, in particular the Public Health Trust/Jackson Health System, the Grady Health System, Johns Hopkins University, Boston Medical Center, Hahnemann University Hospital, Rush University Medical Center, Parkland Health and Hospital System, University of Pittsburgh, University of California Los Angeles, University of Alabama at Birmingham, and Saint Luke’s Roosevelt Hospital, for their support on this project.

Additional Contributions

We thank the following individuals for their contributions to the study. From the University of Miami Miller School of Medicine, Jose Szapocznik, PhD, Viviana Horigian, MD, and Ingrid M. Usaga, MSW, for Florida Node Alliance coordination; Terri Liguori, MEd, EdS, for national implementation coordination; Jessica Ucha, MSEd, Luis Espinoza, MD, and Michael Kolber, MD, PhD, for site coordination; Katie Klose, MSW, Lisa Abreu, MPH, and Laurel Hall, BS, for intervention delivery and data collection; Sara Clingerman, BS, for data collection; Cheryl Walker for outreach and retention assistance; Elizabeth Alonso, PhD, Silvia Mestre, MS, and Aura Pacini, CCRA, for quality assurance; Yue Pan, MS, Rui Duan, MPH, and C. Mindy Nelson, MS, PhD, for data analysis; and Kathleen Mercogliano, RN, and Sheila Findlay, MSW, LCSW, for research assistance. From Columbia University, Iveth Yanez, MPA, for manuscript development and D. Faye Yeomans, AS, for research assistance. From The Village South, Inc, Michael Miller, PhD, for intervention training and assistance. From the San Francisco Department of Public Health, Shannon Huffaker, NP, and Erin DeMicco, MPH, for national clinical coordination and Shawn Demmons, MPH, and Lamont Hernandez, MA, for national intervention coordination and fidelity monitoring. From the University of Washington Donald Calsyn, PhD, for intervention coordination and training. From Friends Research Institute, Robert Schwartz, MD, for Mid-Atlantic Node coordination. From Johns Hopkins University, Jack Chally, MBA, and Heather Fitzsimmons for Mid-Atlantic Node coordination; Katie J. C. Zook, CCRP, for regulatory assistance; Jeanne Keruly, MS, CRNP, and Jasmine Dixon, BS, for site coordination; Rajni Sharma, Melissa Otterbein, and Antionette McCray for intervention delivery and data collection; and Warren Lee for outreach and retention assistance. From Lumen Networks, Leonard Onyiah for development of the intervention tracking system. From the University of Texas Southwestern Medical Center, we thank Madhukar Trivedi, MD, and Robrina Walker, PhD, for Texas Node coordination; Katherine Sanchez, LCSW, PhD, for intervention training and assistance; Mora Kim, MPH, Kathryn Dzurilla, Brittany Eghaneyan, MSSW, and Stacy Abraham, MPH for site coordination and data collection; Mark Vasquez, BS, for data collection; Deneen Robinson and Orlando House for intervention delivery and data collection; Gerald Strickland for outreach and retention assistance and data collection; and Kathy Shores-Wilson, PhD, for regulatory coordination and quality assurance. From Emory University Vincent Marconi, MD, Jonathan Colasanti, MD, Christin Root, BS, and Valarie Hunter for site coordination; Marietta Collins, PhD, and Eugene Farber, PhD, for intervention training and assistance; Christopher Foster, BA, and Charles Fountain for intervention delivery and data collection; Kishna Outlaw, Kelly Dyer, BS, Brooke Peery, MPH, and Leslie McCoy, MBA, for data collection; and Ossie Williams, BS, and Kathy Traylor for outreach and retention assistance. From McLean Hospital, Roger Weiss, MD, for New England Consortium Node coordination; Kathryn McHugh, PhD, for protocol coordination and Scott E. Provost, MM, MSW, for quality assurance. From Boston University Ashley Leech for site coordination; Gena Hong, Jillian Van Zee, Eric LeFevre, and Joy Sylvester for intervention delivery and data collection; and Lynsey Avalone for data collection. From University of Cincinnati, Theresa Winhusen, PhD, and Angela Casey-Willingham, BA, for Ohio Valley Node coordination; Anne Autry, MD, for protocol coordination; Emily Dorer, BS, for regulatory coordination; and Frankie Kropp, MS, for clinical trial coordination. From John H. Stroger, Jr. Hospital of Cook County, Jeffrey Watts, MD, and Sarah Elder, LCSW, CADC, for site coordination; Fabiana Araujo, Allen Ratliff, Rona Clark, Kristin Reitz, and Gabrielle Pendley for intervention delivery and data collection; Felipe Hernandez for data collection; and Eddie Nance and Mishea Robinson for outreach and retention assistance. From the University of Pennsylvania, George Woody, MD, for Delaware Valley Node coordination; Charlotte Royer-Malvestuto, MED, MBE, and Edgar Weiss, MS, for protocol coordination; Peter Smith and Mack Taylor for outreach and retention assistance; and Lin Denton, RN, BSN, for quality assurance. From Drexel University College of Medicine, James K. Robinson, MSW, MPH, for site coordination and Stephanie Josephson, LSW, for intervention delivery and data collection. From Medical University of South Carolina, Kathleen Brady, MD, PhD, and Gail Brubaker, BS, for Southern Consortium Node coordination and Kimberly Pressley, MA, for protocol coordination and quality assurance. From the University of Alabama at Birmingham, Joseph Schumacher, MD, Karen Cropsey, MD, James Willig, MD, D. Scott Batey, MSW, and Heather Coley, MPH, for site coordination; Sandra Roberts for program coordination; DeBran Jacobs, MPH, and Stephanie Gaskin, MHA, for intervention delivery and data collection; and Juan Horton, MSW, for outreach and retention assistance. From the University of California, Los Angeles, Walter Ling, MD, and Albert Hasson, MSW, for Pacific Region Node coordination; Mark Oyama, MBA, and Steve Shoptaw, PhD, for protocol coordination; Sandy MacNicoll, MBA, for quality assurance; Mario Guerrero for site coordination; Pedro Chavez, BA, for intervention delivery and data collection; and Vanessa Correa, BA, for data collection. From the University of Pittsburgh, Dennis Daley, PhD, and Dorothy Sandstrom, MS, for Appalachian Tri-State Node coordination; Peter Veldkamp, MD, and Caroline Baron-Myak, RN, for site coordination; Jacob Johnson, MSC, Anita Barnhart, MSW, and Walitta Abdullah, MS, for intervention delivery and data collection; and Janis McDonald for outreach and retention assistance. From New York State Psychiatric Institute, Edward Nunes, MD, and Jennifer Lima for Greater New York Node coordination; Eva Turrigiano for quality assurance; Megan Ghiroli for site coordination; and Christopher Ferraris for intervention delivery and data collection. From Mount Sinai St Luke’s Hospital, Matthew Berler and Jennifer Derri for intervention delivery and data collection and Joann Gomez and Sylviah Nyamu for data collection. From the Emmes Corporation, Eve Jelstrom CRNA, MBA, for project management; Li Lu, MS, for data analysis; and Ashley Case and Jeremy Wolff for data management. The aforementioned contributors did not receive external compensation outside of their usual salary support.

Funding:

Funding for this study and analysis was provided for the study’s principal investigators by the National Institute on Drug Abuse under the following awards: U10DA013720 and UG1DA013720 (Drs Jose Szapocznik and Lisa R. Metsch); U10DA013035 and UG1DA013035 (Drs John Rotrosen and Edward V. Nunes, Jr); U10DA013034 and UG1DA013034 (Drs Maxine Stitzer and Robert Schwartz); U10DA013727 and UG1DA013727 (Drs. Kathleen T. Brady and Matthew Carpenter); U10DA020024 and UG1DA020024 (Dr Madhukar H. Trivedi); U10DA013732 and UG1DA013732 (Dr Theresa Winhusen); U10DA015831 and UG1DA015831 (Drs. Roger D. Weiss and Kathleen Carroll); U10DA015815 and UG1DA015815 (Drs James L. Sorensen and Dennis McCarty); U10DA020036 (Dr Dennis Daley); U10DA013043 (Dr George Woody); U10DA013045 (Dr Walter Ling); HHSN271200900034C/ N01DA92217 and HHSN271201400028C/ N01DA142237 (Dr Paul Van Veldhuisen); and HHSN271201000024C/N01DA102221 (Dr Robert Lindblad). Support from the University of Miami Center for AIDS Research (CFAR) (P30AI073961; Dr Savita Pahwa), the Emory University CFAR (P30AI050409; Drs Carlos del Rio, James W. Curran, and Eric Hunter), the Atlanta Clinical and Translational Science Institute (UL1TR000454; Dr David Stephens), and the HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute/Columbia University Medical Center (P30MH043520; Dr Robert Remien) is also acknowledged.

Footnotes

Conflicts of Interest: None

Contributor Information

Anthony J. Santella, Hofstra University, Hempstead, NY 11549.

Carrigan Parish, Columbia University, Miami, FL 33101.

Rui Duan, University of Miami, Miami, FL 33101.

Daniel J. Feaster, University of Miami, Miami, FL 33101.

Allan E. Rodriguez, University of Miami, Miami, FL 33101.

Carlos del Rio, Emory University, Atlanta, GA 30322.

Wendy S. Armstrong, Emory University, Atlanta, GA 30322.

Petra Jacobs, National Institutes of Health, Bethesda, MD 20892.

Lisa R. Metsch, Columbia University, New York, NY 10027.

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