Substance Use Screening, Brief Intervention, and Referral to Substance Use Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Pregnant Women Living with HIV Treatment (SBIRT) in Pregnant Women Living with HIV

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Acknowledgments
I cannot express enough appreciation to my faculty advisor, Dr Theresa Nguyen.
Your encouragement, pep talks, emotional support and academic guidance have been invaluable and, as your first student, I hope I have made you proud. I will be forever grateful for the learning opportunities and mentorship you have offered. Thank you for helping keep me on the rails.
To my godmother, Nonie: You have always been an inspiration to me but an encouraging conversation we had when I needed it most made all the difference in the world. You asked me to think if there was ever a time when I had failed at something that I had put my mind to. It was a simple question that helped me dig my heels in and persevere. Thank you and I love you.
To my mom: I literally could not have done this without you. Thank you for the emotional support but, more than anything, thank you for being Spencer's support.
Especially when COVID threw every plan into the shredder, you sacrificed your free time, rest and some days, I'm sure your sanity in order to make sure that I could go to clinical and not worry about my baby. We are so lucky to have you as her Gamma and I can't thank you enough for everything that you do. Thank you for pushing me through what feels like a lifetime of education. I love and appreciate you.
To Spencer: My little love bug, I did this for you as much as I did for myself. I needed to role model resiliency for you. The image of graduating in front of you was the perfect carrot to guide me to the finish line whenever my motivation dimmed. Taking any time away from our time together was difficult and, at times, painful. However, you were in the best of hands whenever I was in class or clinical with either your Grandma or your Daddy and we definitely made up for it with our morning and nightly cuddling. You were with me during my toughest semester and somehow you always knew when to kick, roll or stretch at the moments I needed to refocus. Knowing that your little eyes are always on momma and that the things I do or don't do matter is incredibly motivating and I hope that I make you proud. I'm so proud of everything you've accomplished in the last 14.5 months and am so excited to support you as you start to develop your own passions. You are what anchors me in the difficult times. Your endless support and encouragement have made all the difference in the world. You always believe in me. Knowing that your confidence in me never waivers is what makes me a force to be reckoned with out in the world. Knowing that I have you in my corner allows me to be brave enough to dive into things like pursuing a DNP, changing specialties and starting our family all in the same few years. I can accomplish anything I set my mind to because I am part of an incredibly strong partnership. I see you. I love you with everything I am, and I am so grateful for you.

Description of Clinical Problem
Substance use of any kind during pregnancy can lead to a myriad of social and medical problems for women and babies (World Health Organization, n.d.). Recent data show women are at highest risk of developing a substance use disorder during their reproductive years, which indicates women who are pregnant or about to be pregnant are at an increased risk (Forray, 2016). Data from the 2019 National Survey on Drug Use and Health (NSDUH) indicated use of marijuana has increased in all women surveyed between 2018 and 2019 but has also increased in pregnant women who were screened (NSDUH, 2020). The same survey found tobacco is the most common substance used in pregnancy at 9.6%, followed by alcohol at 9.5%, cannabis at 5.4%, and illicit drugs at 5.8% (NSDUH, 2020). Data indicate substance use in pregnancy is a critical public health concern and women need to be efficiently screened.
Perhaps one of the most vulnerable populations of women in regard to substance use are those living with HIV. Pregnancy is an extremely vulnerable time for women living with HIV. According to Center for Disease Control (Gonzalez et al., 2012), many women are diagnosed with HIV during their pregnancy, and are simultaneously struggling to cope with the new diagnosis, associated stigma, and potential impacts on interpersonal relationships. Other women reengage in HIV care because of a current pregnancy (Gonzalez et al., 2012). Substance use creates a significant challenge for women living with HIV because it contributes to low levels of engagement in treatment and poor medication adherence. Those who use substances intravenously are more than twice as likely to stop antiretroviral therapy compared to those who do not and, in general, have a lower rate of viral suppression than those who do not use substances (Dawson-Rose et al., 2017). Furthermore, women living with HIV who are using substances have suboptimal adherence of their antiretroviral medications (Zhang et al., 2017). As most women strive to have a healthy baby, prenatal care presents a unique opportunity to address HIV, behavioral health/substance use issues, support retention in HIV care, and to optimize viral suppression (Melo et al., 2014). Women are also at high risk of falling out of HIV care following delivery, and effective behavioral health and substance use interventions have been shown to improve and support engagement in HIV primary care and treatment (Gonzalez et al., 2012).
Substance use during pregnancy is as common as many medical conditions routinely screened for in pregnancy, including cystic fibrosis, anemia, perinatal depression, gestational diabetes, or preeclampsia (Wright et al., 2016). Not only is substance use during pregnancy common, it leads to costly and adverse outcomes including, but not limited to, preterm deliveries, low birthweight, birth defects, miscarriages, antepartum hemorrhage, and lengthy antepartum and NICU admissions (Wright et al., 2016). Due to increased rates of perinatal opioid use disorder, there has been a 3-fold increase in neonatal abstinence syndrome (NAS). NAS treatment requires weeks to months in the hospital depending on severity of symptoms (Wright et al., 2016).
Some long-term effects on both mother and infant can be lifelong and require routine medical follow up.
Several governmental and professional organizations offer evidence-based guidelines to minimize potential public health impacts of substance use in pregnant women living with HIV. According to the CDC, universal screening for substance use during pregnancy identifies opportunities to implement interventions which improve maternal and infant health (Wright et al., 2016). United States Preventive Services Task Force (USPSTF) and American Congress of Obstetricians and Gynecologists (ACOG) recommend universal screening (S) for substance use during pregnancy, brief intervention (BI), and referral to treatment (RT) for those who screen positive (American Congress of Obstetricians and Gynecologists, 2017; Chasnoff et al., 1990). Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based intervention designed to identify, reduce, and prevent problematic use of alcohol and drugs. SBIRT allows for tailored services based on risk level reference. Addressing substance use helps improve medication adherence, viral suppression of the mother, and improve postpartum retention in HIV care reference.

Description of Project
The Maternal Child and Adolescent HIV Program (MCAP) at a large medical center serves women and children living with HIV. Its mission is to provide family centered and comprehensive HIV care to women, children, and adolescents. Using a multidisciplinary team of HIV specialists, the clinic provides medical care, patient education, counseling, and case management. The paper will not identify the name of the medical center to protect the identities of those it serves. The MCAP program has a specialized OB/GYN clinic for pregnant and postpartum women living with HIV. This specialized clinic is composed of an OBGYN, nurse practitioner, and licensed social workers.
Historically, clinic substance use screening and assessment was composed of provider specific questions about substance use. Lack of an evidence-based substance use policy resulted in large variation in substance use screening and assessment practices.
Therefore, the clinic sought to enhance services currently provided to pregnant women living with HIV by implementing more effective universal screening, brief intervention, and referral to treatment. This approach allowed for women to be stratified into risk zones based on their pattern of use and by provider discretion. Per SBIRT guidelines, a woman who scores 0-3 is considered low risk (no past usage of alcohol, tobacco, or other drugs, or low levels of use were stopped prior or immediately after discovery of pregnancy), has continued the offered support and remained abstinent from substances (Wright et al., 2016). The women score deemed moderate risk (4-26), which are those who have low level of usage during pregnancy or who have used high quantities of substances in their pregnancy, are given a brief intervention, have motivational interviewing performed and will have frequent follow ups with their provider (Wright et al., 2016). Women identified in the high-risk category (>27), who are those who are actively using illicit substances in their pregnancy and meet criteria for Substance Use Disorder (SUD), are referred to specialized treatment.

Literature Review
The author conducted a literature review to inform this project. The initial literature search involved CINAHL and PubMed databases. Keywords used for this search included pregnant woman, expecting mother, SBIRT, substance use, HIV, brief intervention, reproductive health, and screening. SBIRT research specific to women living with HIV is limited. The following section reviews literature on SBIRT efficacy.

Research from Hostage et al. (2020) demonstrated SBIRT offers a standardized
approach showing screening gaps and areas for improvement. Martino et al. (2018) conducted a randomized control trial (RCT) between September 2011 and January 2015 and randomly placed women using nicotine, alcohol, illicit drugs, or misusing prescription medications into two groups. One group received the standard of care and the other received electronic SBIRT. The researchers performed assessments of the two groups at one, three, and six months after a baseline was established. Implementing SBIRT decreased days of primary substance use in women and did not result in more treatment than those who received usual care (Martino et al., 2018). The implication for practice is an SBIRT tool facilitates substance use documentation and can get targeted treatment to patients in need to decrease their days of substance use.
In a cross-site evaluation of 11 sites and more than one million patients, Babor et al. (2017) employed a multimethod evaluation design to evaluate processes, cost, and outcome of implementation of SBIRT. Pre and post differences were clinically and statistically significant, showing a decrease in substance use and positive outcomes, so 67% of sites continued with SBIRT after grant funding ended (Babor et al., 2017).
Notably, SBIRT also contributed to treatment equity, efficiency, and cost effectiveness. In a meta-analysis of 13 RCTs from Glass et al. (2015), there was no evidence brief intervention for alcohol use was effective in increased use of referral care. Though this meta-analysis did not find SBIRT to be effective, it did show patients with higher severity of substance use and those recruited from more acute settings were more likely to use referral services than those with lower severity scores (Glass et al., 2015). None of the studies analyzed an association between clinical outcomes and treatment use. The RCTs included in this meta-analysis were not designed with the primary focus on referral to treatment. This means there was a lack of data to evaluate whether or not referral and receipt of treatment improved clinical outcomes in brief intervention recipients. Future researchers need to include are clinical trials focusing on referral to treatment as the primary outcome and sufficiently track referral processes.
Another study from Tassiopoulos et al. (2010)  If an infant was found to be HIV infected, the dyad was discontinued from the study and referred to HIV care. Enrolled mothers completed a substance use questionnaire and meconium was collected from their infants. Results found self-reported substance use was reliable when compared to meconium. The implication for practice is this patient demographic can be relied upon with their self-disclosure about substance use. In fact, self-reporting is an even more valuable tool for assessing substance use than meconium collection due to substances such as alcohol and tobacco not being detectable in meconium (Tassiopoulos et al., 2010). The other notable finding is use of illicit substances is low, but alcohol and tobacco exposure is relatively common in pregnancy.
Research on effects of recreational drug use on medication adherence among women is scant. A multicenter RCT from Zhang et al. (2017) assessed adherence of taking a single tablet antiretroviral (STR) versus multi-tablet antiretroviral regimen (MTR) in HIV+ women who use substances. The study found substance use other than marijuana only was associated with suboptimal medication adherence in both STR and MTR users and marijuana use was associated with suboptimum STR adherence (Zhang et al., 2017). This is relevant for practice because substance use was found to be connected to issues with medication adherence in general. Moreover, marijuana specifically impairs STR adherence. This finding significantly impacts patient outcomes, particularly in states with legalized recreational marijuana use.

Evidence Based Practice Model
This Evidence Based Project (EBP) was framed by the IOWA model. The IOWA model is specifically engineered toward evidenced based change inclusive of the entire medical team including physicians, nurses, and allied healthcare providers.
Interdisciplinary teamwork is already a value of the MCAP clinic because they rely on it to manage and optimize their patients' healthcare. Additionally, the project uses one social worker to screen patients, but other medical providers need to be kept informed on the status of screening and whether or not patients are referred to further treatment. As discussed by Hostage et al. (2020), SBIRT relies on interdisciplinary approaches to decrease days of primary substance use.
The project implemented evidence-based practice to identify HIV positive pregnant mothers who are at moderate to high risk for substance use with a universal screening tool. Before implementation, there was no standardized approach or questionnaire to identify women at risk for substance use in their pregnancy.
Consequently, there was a risk of substance-using patients who were not being identified.

Lack of identification increases risk of ARV adherence which further increases risk of
prenatal care adherence which further increases the risk of prenatal care adherence. This ultimately jeopardizes their adherence to prenatal care thereby risking both maternal and newborn health. One of the strengths of the IOWA model is its use of feedback loops (Doody & Doody, 2013), which allow plenty of opportunities for team-based feedback and interdisciplinary feedback. Feedback loops are essential in determining effectiveness and ease of proposed changes for involved personnel. Additionally, this model has been shown to be very effective in development of curriculums for Quality Improvement (QI) projects, EBP research and training/education, and showing positive effect in improvement projects which is the overall goal of evidence-based projects such as this.
Several times over the course of the project, a DNP student was in contact with the screening social worker to inquire about progress, any suggestions for project improvement, and to offer moral support. There were also two opportunities for other members of the clinic team (e.g., physician, nurse practitioner, other licensed social workers) to offer feedback to this student. The author presented the evidence for change prior to the implementation of the project and then disseminated the data at the end. Both opportunities led to brainstorming sessions on how to improve the project moving forward. The clinic designated a specific social worker to perform SBIRT on all the clinic's patients during their initial prenatal appointment. Implementation began in January 2020 and continued through January 2021. At three, six, and nine months I asked for feedback from designated social workers to make any changes or adjustments based on her feedback. The feedback centered on trying to gain access and information from referral sites. Due to being overwhelmed with impacts of COVID-19, referral sites were requiring contact from prospective patients and not the clinic. The DNP student attempted contact with referral sites also but was unsuccessful. The author collected data in January 2021 and a stakeholder presentation was performed in March 2021 to disseminate results.

Data Analysis
Between January 2020 and January 2021, all 15 of the clinic's pregnant patients were included in screening. They ranged from 21-38 years old. Variables assessed included age, screening results, and whether or not they were referred to specialized treatment if deemed high risk. No patients were deemed high risk, 20% (three of 15) were moderate risk, and 80% were assessed as low risk (see Figure 1).

Risk Assessment
The Modified ASSIST identified four patients who used alcohol during their pregnancies and three patients who smoked cigarettes (see Figure 2). Social Worker documentation clarified these patients had stopped smoking upon discovering they were pregnant but screened positive due to NIDA assist's assessment of recent and lifetime use. Two patients indicated methamphetamine use and one was using marijuana with no intention of quitting. Patients who admitted to methamphetamine and marijuana use scored as moderate risk and ultimately scored under the threshold for referral to treatment.

Cost-Benefit Analysis
The financial benefit of SBIRT implementation is mainly looked at in terms of cost avoidance. By avoiding consequences of substance use, there is a cost savings for patients and hospital systems alike. One meta-analysis considered costs of HIV medication nonadherence and found patients spent anywhere between $1,300 and $2,000 per month on nonadherent treatment depending on their viral load, which translates to a range of $16,957-$30,068 per year ( Gonzalez et al., 2011). That is not an insignificant amount to most people, let alone when raising children. Another study showed applying SBIRT was associated with a general reduction in Medicaid costs per member, per month of $366 for those who received a referral and $542 per member, per month for those who received only a brief intervention (Estee et al., 2010). The same study also showed SBIRT has potential to reduce resource consumption among Medicaid patients in hospitals.
Other prospective costs prudent to avoid are those associated with maternal and neonatal complications. Between 2006 and 2012, rates of maternal and neonatal hospitalizations related to substance use increased 33% and 71%, respectively (Agency for Healthcare Research and Quality, 2015). It is safe to assume rates have steadily increased in the near decade since. The same study showed costs of neonatal stays increased by 135% over that time frame from $253.4 million to $594.6 million and cumulatively to $944 million for mothers and neonates (Agency for Healthcare Research and Quality, 2015). Of maternal hospital stays related to substance use in 2012, one-third involved marijuana use and one-fourth involved opioids (Agency for Healthcare Research and Quality, 2015). This supports use of a validated screening tool to identify which substance is being used and how frequently to treat patients properly and avoid unnecessary and costly complications.
The benefit of implementing SBIRT is not solely about cost avoidance. American Medical Association (AMA) has approved several billing codes for SBIRT reimbursement. Reimbursement ranges from $24-$48 for 15 min screenings (American Society of Addiction Medicine, 2017). The screening tool is free to use and, other than one hour for staff training offered during lunch and dedicating a social worker to administering screenings, there is no cost to continue with SBIRT once implemented.
Overall, it is a cost-effective way to improve maternal and neonatal outcomes.

Discussion, Challenges, and Implications
This section will review discussion, challenges and implications of this project.
There were significant challenges to implementation of this project. There were significant challenges to implementation of the project, such as the global pandemic. We did not expect issues such as remote versus in person assessments, cannabis use, COVID-19 impact on referral sites, and comfort level of IRB presented issues. The following section will address each issue.
The first and most notable difficulty was the COVID-19 global pandemic. In March 2020, the clinic moved to a telemedicine platform. The social worker found the change from screening a patient in-person to over phone or Zoom hampered ability to form trust and patients did not fully disclose their substance use. In one instance, the social worker had a patient's chart and substance use history in front of her while conducting the screening and was aware the patient was not being honest with her answers. However, the social worker expressed in person she is able to use eye contact, therapeutic communication, and other techniques to encourage a patient to be open.
There were other implications to remote screening. For some patients, having internet access or a phone is cost prohibitive, which can make telemedicine inequitable.
Many clinic patients have less access to resources and have to rely on library computers or public hotspots for internet connectivity, which is obviously not conducive for telemedicine clinical appointments (Kronenfield & Penedo, 2020). Conducting a substance use screening in an office greatly reduces risk of confidentiality being compromised. Additionally, patients may be impacted by attending telemedicine visits at home with children or other family members present.
Another unseen complication of the global pandemic was impact on referral sites. Clinic staff has historically had difficulties communicating with referral ties prior to COVID-19, but sites became even less communicative after March 2020, likely due to an increase in volume for need in services from patients. Researchers and academics have already been discussing how COVID-19 has caused an increase in substance use and surged interest in treatment (Abramson, 2021). Patients were also impacted and voiced frustration about lack of returned phone calls and inquiries. No patients screened during this project required referral to treatment, but it is a complication deserving consideration and a strategy. Lack of communication is definitely problematic because, even prior to COVID-19, referral sites were limited to offering intakes on certain days of the month.
Limited number of possible days for an intake can be difficult to plan around for women with children in traditional situations. However, delayed communication presents an even bigger challenge for mothers if sites no longer offer childcare due to  precautions and childcare needs to be arranged quickly.
Screening for cannabis use also posed an interesting challenge. In California, cannabis is a legal substance, but it has not been federally decriminalized. This presents another difficulty because screening tools do not account for illicit substances and require a separate question. However, not following exact verbiage of a screening tool as directed  (2020). Results also showed daily or near daily marijuana use among nonpregnant women increased by 4.4%, from 2.2 million to 2.7 million women, and in pregnant women from 35,000 to 36,000 women (SAMHSA, 2020). Women in their reproductive years are at high risk of using substances and data presented by SAMHSA not only corroborates that but shows which substances are trending upward.
No patients endorsing marijuana scored high enough for referral. However, in our final feedback session, clinic staff discussed how patients who endorsed cannabis use were often referred to Child Protective Services. These referrals caused some disconcertion between both staff and patients because marijuana use has become more commonplace, so individuals are viewing it less as an illicit drug and more as a natural alternative to pharmaceuticals. Many patients were unaware disclosing their cannabis use would trigger a CPS referral. Importantly, there is not a specific protocol pertaining to cannabis use and CPS referrals at this facility. California also does not have a clear policy about CPS referral for prenatal marijuana use. Additionally, the lead OB/GYN of the clinic does not consider marijuana to be as concerning as other illicit drugs and he does not routinely follow up on cannabis use in his patients.
The project highlighted this wide variation in clinical practice and could be followed up on by a future student. Although more research needs to be done about consequences of cannabis use in pregnancy, current meta-analyses have linked prenatal cannabis use to low birth weight and preterm labor (Zhang et al., 2017). Potential impacts on neurocognitive and behavioral problems are unknown although several researchers have pointed toward deleterious sequala (Jaques et al., 2014).

Another challenge involved the organization's Human Research Protections
Program and IRB. Given how vulnerable this population is, IRB was very rigorous in ensuring patient's protected information stayed confidential. Initially given "exempt" status, the clinic supervisor requested IRB was made aware the DNP student was no longer an employee of the facility to see if this was still acceptable. Several IRB administrators were unfamiliar with EBP projects and thus unsure whether or not we were conducting research. To ensure IRB administrators were comfortable, we were only given deidentified variables of age, SBIRT score, and whether or not the patient was referred for further treatment.
A limitation to analyzing project outcomes was the previous screening system was provider specific and not universal. Thus, there was no pre data to compare findings.
In addition to a very small sample size (which does not matter with EBP), data collected were much more limited to original outcome variables, birth outcomes, postpartum follow up SBIRT scores, and viral loads.
In conclusion, substance use has been shown to be a consistent barrier to HIV medication adherence. It is also attributed to costly and deadly maternal and neonatal complications and hospitalizations which have become more expensive over time.
Implementing SBIRT to standardize treatment of pregnant women living with HIV is a cost effective, efficient, and evidence-based method to ensure substance use is properly assessed and treated.