HIV risk reduction for substance using gay and bisexual men:

1. HIV risk reduction for substance using gay and bisexual men: A harm reduction approach using group based motivational interviewing

2. Tim Guimond, CAMH Carol Strike, CAMH David Brennan, U of T James Murray, AIDS Bureau Jean Pierre Londono Sanchez, CAMH Jim Cullen, CAMH Karen de Prinse, Casey House Kenneth Tong, Community Le-Ann Dolan, ACT Mark Hallman, SMH Maureen Mahan, Casey House Nick Boyce, Fife House Peggy Millson, U of T Tarry Steckly, Community Winston Husbands, ACT Research Team

3. Rationale • Studies link alcohol and drug consumption with unsafe sexual behaviours among gay/bisexual men • Higher rates of alcohol and drug consumption have been documented amongst gay and bisexual men • Alcohol and drug treatment may reduce risks but few men attend treatment • Motivational interviewing (MI) shows great promise for behavioural change, including sexual and drug and alcohol consumption • MI – client centred, non-judgmental approach focused on assisting individuals to resolve ambivalence toward behaviour change

4. Project objectives • Develop a transdisciplinary team including researchers, clinicians, community-based service providers, policy-makers and community members • Develop an intervention model suitable for community-based settings • Build capacity for group interventions, MI, knowledge sharing and collaboration • Complete a pilot study of the intervention.

5. Research questions Primary • Does group-based motivational interviewing with a harm reduction focus result in reductions in high HIV-risk sexual behaviours (unprotected anal intercourse)? Secondary questions/outcomes: • Are reductions in sexual HIV risk behaviours (if any) mediated by overall reductions in substance use OR situational substance use proximal to sexual activity? • Are there differences between HIV-positive and HIV-negative men in terms of the impact of group based MI on sexual risk reduction? • Does it make a difference if groups are mixed serostatus vs. similar serostatus?

6. Research questions Process/KTE outcomes: • What elements of training, supervision, review and case discussions appear most advantageous in the successful adaptation of motivational interviewing to HIV prevention work? • Do community workers trained in MI, find this approach to be relevant to their other work? • What knowledge, skills, references and supports do community workers feel is necessary for successful application of MI in their practice?

7. Longitudinal intervention conducted with 3 groups (mixed serostatus; HIV negative; HIV positive) Inclusion criteria Age 18 or older In past 60 days, had unprotected anal intercourse with a man while drunk or high English speaking Self identify as gay or bisexual Exclusion criteria Non-substance induced psychotic disorder Actively suicidal Partner, lover, boyfriend of another study participant N=24 – three groups of 8 men Study design

9. 58 # of Contacts 17 Could not be reached 41 Were screened 16 Did not meet eligibility criteria 25 Were eligible 17 HIV-positive 8 HIV-negative Recruitment

10. Measures • Demographics • Sexual orientation and HIV status • Mental health – SCID substance dependence, Beck Depression, Penn State Worry Questionnaire, Social adjustment scale, internalized homophobia scale, HIV knowledge • Readiness ruler for behavioural change • drugs, sexual behaviour in general, unprotected anal intercourse • Importance, confidence, realistic • Timeline follow-back - unprotected sexual events • Gender, HIV status, casual or a regular partner • Sexual behaviours, condom use, location - bathhouse • Drug use before or during sex with this partner • Alcohol consumption before or during sex with this partner

11. 7 wk group based MI using a harm reduction model • GOAL: • Help gay, bi men who use drugs and/or alcohol lead balanced healthy and fulfilling lives by considering the roles drugs play in their life and how to reduce the risks to themselves, their loved ones and the community. • Schedule • Baseline research interview (paid) • Individual pre-group meeting with facilitators to define goals and expectations • 7 group sessions lasting 1.5 hours • Exit interview with facilitators • End of intervention research interview (paid) • 3 month follow-up research interview (paid)

12. Intervention • Week 1 • Introductions, norms/expectations of the group • What drugs do we use, like and dislike • Week 2: How drugs fit in my life • Benefits, impacts and costs of drugs in our lives & those we love • Harm reduction information will be integrated into conversation in this week and next week • Week 3: How drugs fit in my life • Share information about different substances, dispelling myths, harm reduction strategies

13. Intervention • Week 4 – Drugs, sex and sexuality • How drugs fit into our sex lives • Role of drugs, sex and identity in the community • HIV and sexual risk taking and drugs • Week 5 – When this much is too much • Discussion of dependence and drug-related harms • Decisional balance exercise

14. Intervention • Week 6 – Setting my goals • Next steps and goal setting • What might get in the way of this? • Week 7 – My community & closing • How will this work with my friends, my community? • What can we be doing to help those close to us? • What can we be doing to help others in the community? • Say goodbye

15. Baseline data on subjects recruited to date • Five individuals withdrew/were deemed ineligible at baseline hence 20 people are included here: • Age: average 44.3 (s.d. 10.9) • 16 were HIV-positive • 18 identified as gay, 1 as bisexual, and 1 as two-spirited • 17 reported they were single/never married, 2 as separated, and 1 as divorced

16. Baseline demographics (continued) • Highest level of education: 2 some high school, 1 completed high school, 5 some college or university, 2 completed community college, 8 completed university, 2 other • Employment: 1 works full-time, 6 work part-time, 9 not-employed or on disability, 1 self-employed, 3 other (one is a current student) • Income: average $11,234 (s.d. $11,358)

17. Baseline data (continued) • Beck Depression Inventory: avg 16.5 (s.d. 9.8) [n=15] • 6 (30%) reported physical abuse as a child • 2 (10%) reported being sexually abused as a child by a female offender and 9 (45%) by a male offender

18. Lessons learned: Recruitment • Recruitment of HIV – positive subjects was much easier through existing networks of care providers • HIV – negative subjects were much more likely to be marginally housed, and therefore to have less stable contact numbers making it difficult to follow-up with these individuals • Different strategies necessary for HIV – negative men

19. Successes to date - KTE • Participation in training indicative of interest and need for MI within the community • Congruency between counseling approaches used by our community partners and motivational interviewing • Interest in extending MI approach to other programming areas within ASOs • Success with MI approach has positively influenced the ways in which education and outreach are viewed by staff

20. Successes to date : KTE 2 • Training model • Breaking up training over several weeks allows participants to practice integrating the principles from early on in the training • Improved uptake of MI principles and practices • Integration of clinical supervision into the training and especially into the group process has proven quite valuable to facilitators in developing MI facility • Inviting other community agencies to attend free training extended the benefits beyond the focal team to other agencies

21. Moving forward • Recruit and conduct group #3 • Review successes and challenges • Develop strategies to overcome challenges of the group format for implementation in the community • Expand community partnerships for a larger intervention study – extend east, west and north • Consider option of also testing a briefer 1-on-1 model