HIV Prevention in Community-Based Substance Abuse Treatment: The NIDA CTN Safer Sex Skills Building Study for Women

1. HIV Prevention in Community-Based Substance Abuse Treatment: The NIDA CTN Safer Sex Skills Building Study for Women Aimee Campbell, PhD New York State Psychiatric Institute Columbia University College of Physicians & Surgeons

2. Acknowledgements • Susan Tross, Principal Investigator • Co-authors on outcome papers: Mei-Chen Hu, Martina Pavlicova, Gloria Miele, Lisa Cohen • Research Teams and Participants • Research Support • NIDA CTN Greater NY Node Grant U10 DA13035: Nunes & Rotrosen, Co-PIs

3. HIV Prevention in the CTN • In last decade, 5 large-scale HIV-related protocols have been conducted addressing effectiveness and feasibility questions • Screening, Evaluation, and Treatment of HIV/AIDS, Hepatitis C, and STIs (N=2,040) • Reducing HIV-Related Risk Behaviors among IDUs in Residential Detoxification (N=632) • HIV/STI Risk Reduction Intervention for Women (N=515) • HIV/STI Risk Reduction Intervention for Men (N=590) • HIV Rapid Testing and Counseling (N=1,281)

4. HIV Risk in Women • Heterosexual women are among the fastest growing subgroups of people with HIV in the US • Women comprise 27% of new HIV infections; 80% via heterosexual transmission (CDC, 2008) • African American and Latina women at disproportionate risk • Women at greatest risk through primary male sexual partners (St. Lawrence et al., 1998; Weiss, 2000) • Critical factors associated with HIV risk and substance use

5. Features of Effective HIV Prevention Interventions For Women • Gender-specific • Comprehensive, includes skills-building • 4 or more sessions Prendergast et al., 2001; Semaan et al., 2002; Exner et al., 1997

6. Safer Sex Skills-Building (SSSB) HIV Risk Reduction Intervention Session 1: HIV/STI information, testing & counseling Session 2: Personal risk assessment, triggers, supports Session 3: Condom skill building, problem-solving Session 4: Negotiation Session 5: Slips, review, and graduation

7. Theory Social Cognitive Learning Theory Behavior is learned through the social processes of observation, modeling, skill rehearsal, and feedback, especially with one’s peer group Empowerment Theory Individuals are empowered to action by the processes of skill mastery, peer support, and ability to impact on one’s world

8. Underlying Principles • Expected outcomes of behavior • Skills & Self-efficacy • Personal goals • Partner risk assessment/Safety

9. NIDA CTN Safer Sex Skills Building Protocol for Women • 12 Community-based treatment programs across 9 U.S. states • 7 Methadone Maintenance • 5 Outpatient psychosocial • Recruited between May 2004-October 2005 • N=515 women • Intervention co-facilitators and supervisors were recruited directly from participating programs

10. Study Design Baseline Assessment Eligibility Cohort Randomization HIV Education (HE) (1 Session) Safer Sex Skills Building (SSSB) (5 Session) Post Treatment 3 Month FU 6 Month FU

11. Study Sample • Inclusion Criteria • Participating in drug treatment • Unprotected vaginal/anal sex (6 months) • Understand/Speak English • Exclusion Criteria • Immediately planning pregnancy • Cognitive impairment that would affect participation

12. Outcomes • Primary • Unprotected vaginal/anal sex occasions in the prior 90 days • Secondary • Number sexual occasions under the influence of drugs/alcohol • Perceived self-efficacy • Carrying condoms

13. Baseline Characteristics • 46% over the age of 40 • 58% White, 24% Black, 9% Hispanic/Latina • Education • 28% < HS • 38% HS • 34% > HS • 54% reported one sexual partner (monogamy) • 19.3 mean number of unprotected sex acts in prior 3 months

14. Treatment Exposure • Health Education (n=265) • 38% did not attend • 62% completed single session • SSSB (n=250) • 39% did not attend • 18% attended 1 or 2 sessions • 23% attended 3 or 4 sessions • 20% completed all 5 sessions

15. Treatment Fidelity 154 treatment sessions reviewed and rated 78% met adherence – defined as all items coded adequate

16. Primary Outcome Analysis: Unprotected Sex Occasions • Intent to Treat • n=384 (with at least 1 follow-up) • Mixed Effects Model • Random: Site, Cohort, Subject • Fixed: Treatment, Time, Monogamy • Covariate: Baseline USO • Poisson Link Function

17. Intervention Effect on USO

18. Observed (Baseline) and Predicted Means (3, 6 Months) for USO

19. Effect Sizes 3-Month Follow-Up: SSSB and HE both had similar effects (no significant difference) 6-Month Follow-Up: USO decreased by 28% in the SSSB condition compared to HE Effect size of .42

20. Observed and Predicted Means for USO among Completers

21. Summary • Significant difference in the effect of SSSB over time compared to HE at 6-month follow-up; this effect is enhanced by treatment completion • Monogamy status was a significant predictor of USO; women with only one male partner reported 33% more USO than women with more than one male partner Tross et al., 2008

22. Secondary Analysis: Drugs with Sex Occasions • Mixed Effects Model • Random: Subject • Fixed: Treatment, Time • Covariate: program type, monogamy, baseline drugs with sex occasions • Zero-inflated Negative Binomial distribution

23. Intervention Effect on Drugs with Sex Occasions • At 6-month follow up there was a significant difference in the number of drug or alcohol with sex occasions favoring SSSB (p<.03) • Predicted number of drug with sex occasions at 6-month: • SSSB=6.52 (-17 from baseline) • HE=14.85 (-12 from baseline)

24. Summary • Similar pattern to unprotected sex outcome: although drugs with sex occasions decreased for both groups at 3-month follow up, reductions continued at 6-month for the SSSB group. • No differences between SSSB and HE on substance use or injection drug use outcomes

25. Post-study Provider Attitude Survey

26. Post-Study Provider Survey Methods • Administered to clinical providers and program directors (N=116) to assess attitudes towards clinical and service impact and research impression • Respondents participated in both the women’s and men’s HIV Risk Reduction Studies (15 programs)

27. Examples of Attitudes and Perceptions • Clinical Impact • Identified extra clinical problems • Helped make me a better clinician • Increased discussion of sexual issues • Research Impression • Increased awareness of research procedures • Disrupted day to day operations • Researchers only people to benefit

28. Survey Findings • Staff who directly participated reported: • Intervention components as more useful • Increases in HIV testing/referrals at site • However, those directly involved in the studies reported less positive attitudes regarding clinical impact and research • Higher study attendance rates corresponded to better clinical impact attitudes (men only) Campbell et al., 2012

29. Implications

30. Implications for Social Work • Findings support the use of comprehensive HIV risk reduction interventions to • Reduce unprotected sexual acts • Reduce sexual acts while intoxicated • The persistence of reduction in sexual risk among SSSB clients is encouraging • Primary partnerships and female-controlled methods of protection are critical components for women

31. Implications for Social Work • Brief, evidence-based, HIV interventions can be implemented into substance abuse treatment work with focused training and ongoing support • But require better integration within program curriculum to address attendance issues and sustainability

32. Implications for Social Work • Effectiveness trials can address important adoption and implementation issues (training, acceptability, feasibility, client outcomes) • But they are only part of the solution to the research/practice gap • And can be improved upon to better support providers and promote sustainability

33. Implications for Social Work • Issues of cost effectiveness and reimbursement must be a primary focus of effectiveness studies • Positive study outcomes and perceived intervention usefulness are not sufficient • Evaluation of adoption, implementation, and maintenance efforts and barriers remains critical

34. SSSB among the CDC’s Good-Evidence Interventions http://www.cdc.gov/hiv/topics/research/prs/evidence-based-interventions.htm

35. SSSB Manual: CTN Dissemination Library Website http://ctndisseminationlibrary.org

36. Thank you! Contact Information Aimee Campbell anc2002@columbia.edu