The Substance Abuse Treatment to HIV care (SAT2HIV-II) Project

Despite its relevance to public health, the integration of substance use services into HIV service settings has
been limited to date. Substance misuse interventions such as motivational interviewing (MI) have been
effective in clinical trials but can be challenging to implement in practice settings, including HIV community-based
organizations (HIV-CBOs) that are essential to HIV care. Since 2014, the proposed research team has
been conducting some of the most innovative, large-scale implementation research on this topic as part of the
Substance Abuse Treatment to HIV Care (SAT2HIV) project. Funded by the National Institute on Drug Abuse
(NIDA), this 39-site, dual-randomized, type 2 effectiveness-implementation hybrid trial simultaneously tested
(1) the effectiveness of an MI-based brief intervention (MIBI) for substance misuse as an adjunct to usual care
and (2) the effectiveness of team-focused Implementation & Sustainment Facilitation (ISF) as an adjunct to the
Addiction Technology Transfer Center’s (ATTC’s) staff-focused strategy (i.e., online training + in-person
training + feedback + consultation). Results from the SAT2HIV project showed that the ATTC+ISF strategy
significantly improved implementation effectiveness (i.e., consistency and quality of implementation) and
intervention effectiveness (i.e., effectiveness of MIBI to reduce substance misuse). However, even in the
ATTC+ISF condition, room for improvement in implementation remained. Additionally, neither study condition
resulted in sufficient sustainment. Thus, there is a need for implementation research to identify strategies that
can further improve outcomes beyond the ATTC+ISF strategy. According to implementation effectiveness
theory, implementation climate (i.e., the extent to which implementation is expected, supported, and rewarded)
is a key mechanism of change through which an implementation strategy impacts implementation
effectiveness. Although the ISF strategy already seeks to maximize implementation effectiveness by improving
implementation climate, the proposed research team’s prior implementation research suggests that pay-for-performance
(P4P; i.e., monetary bonuses for achieving predefined targets) is a strategy that may significantly
enhance the effectiveness of the ATTC+ISF strategy. Thus, our research team proposes the SAT2HIV-II
project, a 30-site, cluster-randomized, type 3 effectiveness-implementation hybrid trial to test the effectiveness
of P4P (i.e., compare the ATTC+ISF strategy and the ATTC+ISF+P4P strategy) to significantly improve
implementation outcomes (primary aim) and client outcomes (secondary aim). The 2019 Ending the HIV
Epidemic initiative seeks to end the HIV epidemic within 10 years. This goal is achievable but may not be
possible without improving the extent to which substance use services are integrated into HIV service settings.
Although the SAT2HIV-II project focuses on testing strategies to improve the integration of an MIBI for
substance misuse, the knowledge gained could help HIV-CBOs improve the integration of other innovations.
As such, the SAT2HIV-II project has potential to have a large and sustained impact on improving public health.

Grant Number: 5R01DA052294-05
NIH Institute/Center: NIH
Principal Investigator: ALICIA BUNGER