Transcript CTN-0019: HIV/STD Safer Skills Groups For Women In Methadone

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
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
HIV Prevention in the CTN

In last decade, 5 large-scale HIV-related
protocols have been conducted addressing
effectiveness and feasibility questions
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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)
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
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
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
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

Underlying Principles
Expected outcomes of behavior
 Skills & Self-efficacy
 Personal goals
 Partner risk assessment/Safety

NIDA CTN Safer Sex Skills
Building Protocol for Women
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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
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
Study Sample

Inclusion Criteria
Participating in drug treatment
 Unprotected vaginal/anal sex (6 months)
 Understand/Speak English

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Exclusion Criteria
Immediately planning pregnancy
 Cognitive impairment that would affect
participation
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Outcomes
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Primary
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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
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Baseline Characteristics
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46% over the age of 40
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58% White, 24% Black, 9% Hispanic/Latina
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Education
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28% < HS
38% HS
34% > HS
54% reported one sexual partner (monogamy)
19.3 mean number of unprotected sex acts in
prior 3 months
Treatment Exposure
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Health Education (n=265)
38% did not attend
 62% completed single session
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SSSB (n=250)
39% did not attend
 18% attended 1 or 2 sessions
 23% attended 3 or 4 sessions
 20% completed all 5 sessions
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Treatment Fidelity
154 treatment sessions reviewed and
rated
 78% met adherence – defined as all
items coded adequate
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Primary Outcome Analysis:
Unprotected Sex Occasions
Intent to Treat
 n=384 (with at least 1 follow-up)
 Mixed Effects Model
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Random: Site, Cohort, Subject
 Fixed: Treatment, Time, Monogamy
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Covariate: Baseline USO
 Poisson Link Function
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Intervention Effect on USO
F
p-value
log(Baseline USO)
71.55
<.001
Monogamy
24.42
<.001
Treatment
0.73
0.395
Time
39.60
<.001
Time * Treatment
67.18
<.001
Observed (Baseline) and Predicted
Means (3, 6 Months) for USO
Unprotected sexual occasions
30
25
20
15
10
5
0
HE
SSB
Baseline (obsrvd)
3 months (pred)
6 months (pred)
19.96
17.33
24.14
18.6
15.08
13.96
Tim e
HE
SSB
Effect Sizes
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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
Observed and Predicted Means
for USO among Completers
30
Unprotected sexual occasions
25
20
15
10
5
0
Baseline (obsrvd)
3 months (pred)
6 months (pred)
HE
21.35
16.07
26.38
SSB
14.34
13.37
10.52
Tim e
HE
SSB
Summary
Significant difference in the effect of
SSSB over time compared to HE at 6month 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
Secondary Analysis:
Drugs with Sex Occasions
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Mixed Effects Model
Random: Subject
 Fixed: Treatment, Time
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Covariate: program type, monogamy,
baseline drugs with sex occasions
 Zero-inflated Negative Binomial
distribution
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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:
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SSSB=6.52 (-17 from baseline)
 HE=14.85 (-12 from baseline)
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Summary
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Similar pattern to unprotected sex
outcome: although drugs with sex
occasions decreased for both groups at 3month follow up, reductions continued at 6month for the SSSB group.
No differences between SSSB and HE on
substance use or injection drug use
outcomes
Post-study Provider Attitude
Survey
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)
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Examples of Attitudes and
Perceptions
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Clinical Impact
Identified extra clinical problems
 Helped make me a better clinician
 Increased discussion of sexual issues
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Research Impression
Increased awareness of research
procedures
 Disrupted day to day operations
 Researchers only people to benefit
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Survey Findings
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Staff who directly participated reported:
Intervention components as more useful
 Increases in HIV testing/referrals at site
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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
Implications
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 femalecontrolled methods of protection are
critical components for women
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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
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

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
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SSSB among the CDC’s GoodEvidence Interventions
http://www.cdc.gov/hiv/topics/research/prs/evidence-based-interventions.htm
SSSB Manual: CTN
Dissemination Library Website
http://ctndisseminationlibrary.org
Thank you!
Contact Information
Aimee Campbell
[email protected]