(3) Substance Use Treatment Utilization Among Community-Supervised Individuals at Risk for HIV

Background & Introduction: Approximately two-thirds of individuals in the United States criminal legal (CL) system are under community supervision (probation or parole), with opioid use rates surpassing the general population by over fivefold. This heightened prevalence poses significant health concerns, including an elevated risk of HIV transmission. Medications for opioid use disorders (MOUDs), such as methadone and buprenorphine, are proven to be more effective than standalone detoxification and inpatient or outpatient substance use disorder (SUD) treatment services in reducing opioid use and overdose-related deaths. Further, MOUD receipt has demonstrated benefits in reducing criminal recidivism and HIV transmission while promoting engagement with HIV-related services, underscoring their importance for CL system-involved individuals.
Despite these advantages, knowledge gaps persist regarding MOUD utilization among CL system-involved individuals using illicit opioids at risk for HIV. Gaining insight into the SUD treatment landscape within this specific population is crucial for shaping initiatives to address the intersecting epidemics of opioid use and HIV. To address this, our study examined SUD treatment utilization among individuals under community supervision with illicit opioid use and HIV risk. Given evidence of SUD treatment disparities in national samples based on race/ethnicity, gender identity, and sexual orientation, we also examined demographic characteristics associated with treatment receipt.

Methods: Data for the present study were drawn from the Southern Pre-Exposure Prophylaxis Study (SPECs), which focused on individuals under community supervision in North Carolina (NC), Kentucky (KY), and Florida (FL) who were clinically indicated for pre-exposure prophylaxis (PrEP) and therefore at high risk for HIV. Eligibility for SPECs included individuals aged 18 or older, placed on community supervision within the past 12 months, HIV negative, and eligible for PrEP.
The present study utilized SPECs baseline data with a specific focus on participants indicating illicit opiate use, defined as self-reported use of heroin and/or other opiates/analgesics (e.g., codeine, hydrocodone, oxycodone, morphine, fentanyl) without a doctor's prescription. Descriptive analyses were used to identify the rates of treatment utilization and types of treatment received by individuals in our sample, which were stratified by race/ethnicity. Bivariate analyses were used to explore associations between treatment utilization and demographic characteristics, assessed via self-report, and included sexual orientation, gender identity, age, and race/ethnicity.
Bivariate associations were estimated using prevalence ratios (PRs) and 95% confidence intervals (CI) from log-binomial models. Complete case analyses were conducted, and missing data were excluded.

Results: Between June 2019 and August 2022, SPECs conducted 1136 screenings, enrolling 364 eligible participants who completed a baseline visit. Of these participants, 211 (58.0%) indicated illicit opioid use and were included in the present analysis. The average participant age was 35.8 years (SD = 10.2), and participants were predominantly male (66.4%), heterosexual (81.0%), and White non-Hispanic (59.2%). A majority (57.3%) were on probation, with 42.2% on parole/post-release supervision.
Concerning treatment utilization, 73.9% of participants (n = 156) reported engaging in some form of SUD treatment. Bivariate analyses revealed lower treatment prevalence among non-White non-Hispanic participants (Black non-Hispanic versus White non-Hispanic [PR=0.64, 95% CI: 0.60, 1.00, p=0.046], Hispanic/Latinx versus White non-Hispanic [PR=0.77, 95% CI: 0.47, 0.86, p=0.0030], and other versus White non-Hispanic [PR=0.59, 95% CI: 0.33, 1.04, p=0.070]. Treatment utilization was not statistically significantly associated with sexual orientation, age, or gender identity.
Among the 156 participants who received SUD treatment, the most commonly utilized modalities were inpatient services (71.8%), detoxification services (47.4%), and Narcotics Anonymous (NA; 46.8%). Only 37.8% of treated participants reported receiving MOUD, with higher usage observed among White non-Hispanic participants (50.0%) compared to Black non-Hispanic (14.3%) and Hispanic/Latinx participants (4.4%).

Conclusion & Discussion: Findings from the present study revealed high rates of SUD treatment engagement, with nearly three-fourths of individuals in our sample participating in some form of SUD services. These results converge with previous research indicating higher SUD treatment usage among system-involved individuals than in community samples, emphasizing this system’s unique potential to engage a high-risk population in vital services. However, racial disparities in SUD treatment utilization were observed. Specifically, Black non-Hispanic and Hispanic/Latinx participants reported lower SUD treatment prevalence than their White non-Hispanic counterparts. Further, despite the established efficacy of MOUD for opioid use, the majority of participants received inpatient services, and MOUD usage was most prevalent among White non-Hispanic participants.
Taken together, results from the present study highlight missed opportunities for evidence-based care for opioid use among individuals under community supervision at risk for HIV. The relatively low usage of MOUD among participants who reported receiving treatment, particularly among non-White non-Hispanic individuals, signals potential barriers or disparities in accessing evidence-based pharmacological treatments. These findings emphasize the urgency of targeted efforts to promote MOUD adoption among individuals in the CL system who use illicit opioids and are at risk for HIV—particularly racially minoritized populations.

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