Impact of drug treatment on subsequent sexual risk behavior in a multisite cohort of drug-using women: a report from the Women's Interagency HIV Study

A randomized clinical trial evaluating the impact of counselor training and patient feedback on substance use disorder patients' sexual risk behavior

INTRODUCTION

High risk sex-such as sex with multiple partners, condomless sex, or transactional or commercial sex-is a risk factor in individuals with substance use disorders (SUDs). SUD treatment can reduce sexual risk behavior, but interventions to reduce such behavior in this context have not been consistently effective. This study sought to determine if the impact of treatment on sexual risk behavior can be increased.

METHODS

In a nested 2 × 2 factorial repeated measures design, we examined outcomes of two interventions: training for counselors in talking to patients about sexual risk; and availability to both counselors and patients of a personalized feedback report based on patient self-report of sexual behavior. Counselors received either a brief, information-based, Basic Training, or a multi-session, skills-based Enhanced Training. Their patients completed an audio-assisted computerized assessment of sexual behavior and received either No Feedback or a Personalized Feedback Report (PFR). Four hundred seventy six patients participated. Patient follow-up occurred 3- and 6-months postbaseline. Primary patient outcome measures were Number of Unsafe Sex Occasions (USO) and whether patients reported talking about sex in counseling sessions (Discussed Sex), both in the past 90 days. Secondary outcomes included Number of Sexual Partners, Sex Under the Influence of Substances, and Perceived Condom Barriers.

RESULTS

Patients of Enhanced-condition counselors compared to those of Basic-condition counselors were more likely to report talking about sex with their counselor at 6-month follow-up. Personalized feedback also increased the likelihood of reporting counselor discussions at 6-month follow-up. Neither the training nor the feedback condition affected USO, Number of Partners, or Sex Under the Influence.

DISCUSSION

We discuss why these two interventions apparently altered counselor-patient communication about sexual risk behavior without affecting the behavior itself.

Prevalence, Comorbidity, and Correlates of Psychiatric and Substance Use Disorders and Associations with HIV Risk Behaviors in a Multisite Cohort of Women Living with HIV

We used the World Health Organization’s Composite International Diagnostic Interview to determine the prevalence, comorbidity, and correlates of lifetime and 12-month behavioral health disorders in a multisite cohort of 1027 women living with HIV in the United States. Most (82.6%) had one or more lifetime disorders including 34.2% with mood disorders, 61.6% with anxiety disorders, and 58.3% with substance use disorders. Over half (53.9%) had at least one 12-month disorder, including 22.1% with mood disorders, 45.4% with anxiety disorders, and 11.1% with substance use disorders. Behavioral health disorder onset preceded HIV diagnosis by an average of 19 years. In multivariable models, likelihood of disorders was associated with women’s race/ethnicity, employment status, and income. Women with 12-month behavioral health disorders were significantly more likely than their counterparts to engage in subsequent sexual and substance use HIV risk behaviors. We discuss the complex physical and behavioral health needs of women living with HIV.

Associations of place characteristics with HIV and HCV risk behaviors among racial/ethnic groups of people who inject drugs in the United States

PURPOSE

Investigate whether characteristics of geographic areas are associated with condomless sex and injection-related risk behavior among racial/ethnic groups of people who inject drugs (PWID) in the United States.

METHODS

PWID were recruited from 19 metropolitan statistical areas for 2009 National HIV Behavioral Surveillance. Administrative data described ZIP codes, counties, and metropolitan statistical areas where PWID lived. Multilevel models, stratified by racial/ethnic groups, were used to assess relationships of place-based characteristics to condomless sex and injection-related risk behavior (sharing injection equipment).

RESULTS

Among black PWID, living in the South (vs. Northeast) was associated with injection-related risk behavior (adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.21-4.17; P = .011), and living in counties with higher percentages of unaffordable rental housing was associated with condomless sex (AOR = 1.02, 95% CI = 1.00-1.04; P = .046). Among white PWID, living in ZIP codes with greater access to drug treatment was negatively associated with condomless sex (AOR = 0.93, 95% CI = 0.88-1.00; P = .038).

CONCLUSIONS

Policies that increase access to affordable housing and drug treatment may make environments more conducive to safe sexual behaviors among black and white PWID. Future research designed to longitudinally explore the association between residence in the south and injection-related risk behavior might identify specific place-based features that sustain patterns of injection-related risk behavior.

An exploratory study of mental health and HIV risk behavior among drug-using rural women in jail

OBJECTIVE

Rural women, particularly those in the criminal justice system, are at risk for HIV related to the increasing prevalence of injection drug use as well as limited services. Research on HIV risk correlates, including drug use and mental health, has primarily focused on urban women incarcerated in prisons. The purpose of this exploratory study is to examine dual HIV risk by 3 different mental health problems (depression, anxiety, and posttraumatic stress disorder [PTSD]) among drug-using women in rural jails.

METHOD

This study involved random selection, screening, and face-to-face interviews with 136 women in 1 Appalachian state. Analyses focused on the relationship between mental health and HIV risk.

RESULTS

Nearly 80% of women self-reported symptoms of depression, and more than 60% endorsed symptoms consistent with anxiety and PTSD symptoms. Mental health significantly correlated with severity of certain types of drug use, as well as risky sexual activity. In addition, for women experiencing anxiety and PTSD, injection drug use moderated the relationship between mental health and risky sexual activity.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Based on these rates of drug use, mental health problems, and the emergence of injection drug use in rural Appalachia, the need to explore the relationships between these issues among vulnerable and understudied populations, such as rural women, is critical. Because of service limitations in rural communities, criminal justice venues such as jails provide opportune settings for screening, assessment, and intervention for drug use, mental health, and HIV education and prevention. (PsycINFO Database Record

Effectiveness of secondary prevention and treatment interventions for crack-cocaine abuse: a comprehensive narrative overview of English-language studies

There are an estimated several million crack-cocaine users globally; use is highest in the Americas. Most crack users are socio-economically marginalized (e.g., homeless), and feature elevated risks for morbidity (e.g., blood-borne viruses), mortality and crime/violence involvement, resulting in extensive burdens. No comprehensive reviews of evidence-based prevention and/or treatment interventions specifically for crack use exist. We conducted a comprehensive narrative overview of English-language studies on the efficacy of secondary prevention and treatment interventions for crack (cocaine) abuse/dependence. Literature searches (1990-2014) using pertinent keywords were conducted in main scientific databases. Titles/abstracts were reviewed for relevance, and full studies were included in the review if involving a primary prevention/treatment intervention study comprising a substantive crack user sample. Intervention outcomes considered included drug use, health risks/status (e.g., HIV or sexual risks) and select social outcome indicators. Targeted (e.g., behavioral/community-based) prevention measures show mixed and short-term effects on crack use/HIV risk outcomes. Material (e.g., safer crack use kit distribution) interventions also document modest efficacy in risk reduction; empirical assessments of environmental (e.g., drug consumption facilities) for crack smokers are not available. Diverse psycho-social treatment (including contingency management) interventions for crack abuse/dependence show some positive but also limited/short-term efficacy, yet likely constitute best currently available treatment options. Ancillary treatments show little effects but are understudied. Despite ample studies, pharmaco-therapeutic/immunotherapy treatment agents have not produced convincing evidence; select agents may hold potential combined with personalized approaches and/or psycho-social strategies. No comprehensively effective 'gold-standard' prevention/treatment interventions for crack abuse exist; concerted research towards improved interventions is urgently needed.

Risk behavior among women enrolled in a randomized controlled efficacy trial of an adenoviral vector vaccine to prevent HIV acquisition

OBJECTIVES

Report of risk behavior, HIV incidence, and pregnancy rates among women participating in the STEP study, which is a phase IIB trial of MRKAd5 HIV-1 gag/pol/nef vaccine in HIV-negative individuals who were at high risk of HIV-1.

DESIGN

Prospective multicenter, double-blinded, placebo-controlled trial.

METHODS

Women were from North American, and from Caribbean and South America (CSA) sites. Risk behavior was collected at screening and 6-month intervals. Differences in characteristics between groups were tested with chi-square, two-sided Fisher's exact tests, and Wilcoxon rank-sum tests. Generalized estimating equation models were used to assess behavioral change.

RESULTS

Among 1134 enrolled women, the median number of male partners was 18; 73.8% reported unprotected vaginal sex, 15.9% unprotected anal sex and 10.8% evidence of a sexually transmitted infection in the 6 months prior to baseline. With 3344 person-years of follow-up, there were 15 incident HIV infections: incidence rate was 0.45 per 100 person-years [95% confidence interval (CI) 0.25, 0.74]. Crack cocaine use in both regions [relative risk (RR) 2.4 (1.7, 3.3)] and in CSA, unprotected anal sex [RR 6.4 (3.8, 10.7)], and drug use [RR 4.1 (2.1, 8.0)] were baseline risk behaviors associated with HIV acquisition. There was a marked reduction in risk behaviors after study enrollment with some recurrence in unprotected vaginal sex. Of 963 nonsterilized women, 304 (31.6%) became pregnant.

CONCLUSION

Crack cocaine use and unprotected anal sex are important risk criteria to identify high-risk women for HIV-efficacy trials. Pregnancy during the trial was a common occurrence and needs to be considered in trial planning for prevention trials in women.

HIV/STI Risk Behavior of Drug Court Participants

Drug abusing offenders have high rates of HIV and other sexually transmitted infections (STI). To date, the HIV/STI prevention needs of offenders in drug court programs have been ignored. This multi-method study employed interviews to assess drug court professionals' perceptions of the need for an HIV risk reduction intervention to be integrated into the services provided to drug court participants. Then, surveys were completed by 235 drug court participants to assess whether their sexual risk behaviors affirmed the need for such an intervention. The survey also assessed demographic characteristics, drug use prior to program entry, HIV knowledge, and condom attitudes. The relationship between duration in the drug court program and sexual risk behavior was also examined. Implications for the development and delivery of HIV risk reduction interventions within drug court programs are discussed.

Ethnic differences in HIV risk behaviors among methadone-maintained women receiving contingency management for cocaine use disorders

OBJECTIVE

To identify ethnic differences in HIV risk behaviors among cocaine using women receiving methadone maintenance for opioid dependence, and to evaluate the efficacy of contingency management (CM) for cocaine use disorders in reducing HIV risk behaviors.

METHODS

African American (N=47), Hispanic (N=47), and White women (N=29) were randomized to standard methadone treatment or standard methadone treatment plus a CM intervention. They completed the HIV Risk Behavior Scale (HRBS) indicating frequency of drug use and sexual behaviors across the lifetime, in the month before baseline, and in the 3 months following clinical trial participation. Ethnic group differences and the effect of CM on change in HIV risk behaviors between baseline and follow-up were evaluated.

RESULTS

White women reported significantly higher lifetime rates of risky drug use and sexual behaviors on the HRBS than African American women; neither group differed significantly from Hispanic women. No ethnic group differences in HIV risk behaviors were identified in the month prior to baseline. At follow-up, African American women reported fewer high-risk drug use behaviors than White or Hispanic women, and Hispanic women reported more high-risk sexual behaviors than White or African American women. CM was associated with reduction in high-risk drug use behaviors regardless of ethnicity, but did not affect high-risk sexual behaviors.

CONCLUSIONS

White women receiving methadone maintenance engage in more lifetime HIV risk behaviors than African American women. CM for cocaine use reduces risky drug use behaviors, but certain ethnic groups may benefit from additional targeted HIV prevention efforts.

Condom Use Self-Efficacy among Young Adult Ecstasy Users

Relying upon a sample of 283 young adult ecstasy users, this research examines three primary research questions: How high/low are young adult ecstasy users' levels of condom use self-efficacy? How does condom use self-efficacy relate to actual condom use in this population? What factors underlie condom efficacy levels in this population? The study entailed face-to-face interviews that were completed with the use of computer-assisted structured interviews (i.e., CASI). Study participants were recruited in the Atlanta, Georgia metropolitan area between August 2002 and August 2004 using a targeted sampling and ethnographic mapping approach. Interviews took approximately two hours to complete. Condom use self-efficacy levels were found to be fairly high in this population. A strong, direct relationship was observed between condom use self-efficacy and actual condom use. Using a multiple regression approach, five factors were found to be predictive of greater condom use self-efficacy in this population. These were educational attainment, amount of communication in one's family of origin, having asked about one's most recent casual sex partner's HIV serostatus, no prior drug treatment, and level of self-esteem.

Longitudinal HIV risk behavior among the Drug Abuse Treatment Outcome Studies (DATOS) adult sample

Longitudinal trajectories for HIV risk were examined over 5 years following treatment among 1,393 patients who participated in the nationwide Drug Abuse Treatment Outcome Studies. Both injection drug use and sexual risk behavior declined over time, with most of the decline occurring between intake and the first-year follow-up. However, results of the application of growth mixture models for both sets of trajectories indicated that a subgroup of individuals reverted to a high-risk behavior over time, with a higher level of risk at the 5-year follow-up than their original risk level at intake. Of clients who were engaged in regular injection drug use at intake, 76% continued to inject drug at a moderate-stable or increased rate during the 5-year follow-up.