Efficacy of a behavioral intervention for increasing safer sex behaviors in HIV-positive MSM methamphetamine users: Results from the EDGE study
Introduction
Methamphetamine use has become widespread in the United States. In 2006, 48% of law enforcement officials from 500 counties in 44 states identified methamphetamine as the number one drug problem in their county (NACO, 2006). Approximately 12 million Americans are estimated to have used methamphetamine in their lifetime and 1.4 million persons use it in a given year (USDHHS, 2005). Of persons using methamphetamine in the past month, the number of persons meeting criteria for stimulant abuse or dependence increased from 63,000 (10.6%) in 2002 to 130,000 (22.3%) in 2004 (USDHHS, 2005). On a global level, the United Nations Office on Drugs and Crime (UNODC) estimates that amphetamine-type stimulants account for 10% of treatment demand, affecting 34 million people worldwide aged 15 and above (United Nations Office on Drugs et al., 2003).
Methamphetamine is the most widely used drug among men having sex with men (MSM) in the Western U.S. states, and individuals who use methamphetamine are at increased risk of acquiring HIV and other sexually transmitted infections (STIs; Clatts et al., 2005, Fernández et al., 2005, Halkitis et al., 2001, Purcell et al., 2001, Boddiger, 2005, Urbina and Jones, 2004). Methamphetamine appears to play an important role in sexual risk behaviors, particularly at the psychological level. Semple et al. (2002) reported that up to 84% of methamphetamine-using MSM engage in sexual risk behavior when high. Other studies of MSM documented strong associations between methamphetamine use and high risk sexual behaviors including unprotected insertive and receptive anal sex with casual partners, decreased use of condoms, and increased likelihood of acquiring STIs (Halkitis et al., 2001, Molitor et al., 1998, Reback and Ditman, 1997, Reback et al., 2004, Shoptaw et al., 2002). Interventions for reducing sexual risk behaviors of methamphetamine users should therefore focus on underlying motivations for drug use and unsafe sex and providing skills for practicing safer sex in the context of their methamphetamine use.
Psychosocial interventions for reducing HIV/STI risk among drug users have almost exclusively attempted to simultaneously reduce both drug use and sexual risk behaviors (Coyle et al., 1998, Metzger et al., 1998, Neaigus, 1998). In general, interventions have been more successful in reducing high risk drug-using behaviors (e.g., drug injection, multiperson reuse of syringes and needles) than sexual risk behaviors (Booth and Watters, 1994, Gibson et al., 1998). Moreover, these interventions have targeted injection drug users, most of whom are heterosexual (Kanouse et al., 2005). There is a paucity of HIV prevention interventions that target drug-using MSM, particularly non-injection drug users (Johnson et al., 2003). Two studies that used data from treatment-seeking methamphetamine-using MSM demonstrated significant decreases in sexual risk behavior and increases in safer sex behavior across time (Reback et al., 2004, Shoptaw et al., 2005), supporting the notion that drug-using MSM can benefit from sexual risk reduction interventions.
This study examined the efficacy of a theory-based, psychosocial intervention for reducing sexual risk behavior among HIV-positive, methamphetamine-using MSM within the context of ongoing drug use. Our exclusive focus on changing sexual behavior without changing drug use behavior is unique in HIV prevention research and is important for a number of reasons. First, while pharmacologic interventions to treat methamphetamine addiction are under study, such treatments are not widely available. Given the urgency of controlling the spread of HIV among methamphetamine-using MSM, and that few intervention trials designed specifically for HIV-positive individuals have been published, it is imperative to test the efficacy of programs that target sexual risk behaviors in the absence of drug abatement or reduction goals. Second, sexual risk reduction programs that do not emphasize change in drug use behavior may have a broader appeal among out-of-treatment methamphetamine users who are not ready to change their drug use but are concerned about their sexual risk behavior. Such programs, if offered through community-based organizations, could reach large numbers of methamphetamine users and help to reduce HIV/STI transmission in this high risk population.
Our intervention integrates a clinical approach (i.e., motivational interviewing) with principles from both social cognitive theory (Bandura, 1986, Bandura, 1994) and the theory of reasoned action (Ajzen, 1991). Motivational interviewing is a client-centered, process-oriented counseling approach that has been found to be very effective with alcoholics and drug users (Miller and Rollnick, 1991). It incorporates feedback on current behavior, emphasizes readiness for change and personal responsibility for change, delineates alternative strategies for changing problem behaviors, promotes counselor empathy and warmth, and reinforces self-efficacy (Miller and Rollnick, 1991). Social cognitive theory and the theory of reasoned action use role-playing and modeling to enhance knowledge and self-efficacy for safer sex behavior (e.g., condom use, negotiation of safer sex) along with the enhancement of positive social supports. The theoretical framework for our intervention was selected on the basis of our previous intervention study, which demonstrated reductions in sexual risk behaviors in a sample of mostly HIV-positive non-drug-using MSM (Patterson et al., 2003). Motivational interviewing was added to the protocol as an adjunct designed to enhance the theory-driven, positive behavior change effects that were demonstrated in our previous work.
We predicted that compared to those randomized to a general health intervention emphasizing diet and exercise, participants in the intervention condition would demonstrate a significant increase in protected sex behavior and a significant reduction in unprotected sex behaviors over the course of a 12-month randomized controlled trial. Based on a previous finding that demonstrated a strong association between self-efficacy and sexual risk behavior among HIV-positive MSM (Semple et al., 2000), we hypothesized that self-efficacy for condom use and negotiation would increase significantly over time among participants in the intervention condition who received social skills training as compared to control participants.
Section snippets
Participants
HIV-positive methamphetamine-using MSM residing in San Diego County, California, USA were recruited into the EDGE study between November 1999 and November 2004. Recruitment sources included gay organizations and groups, HIV-specialty health clinics, gay-identified venues and events, and referrals from care providers. Most participants were recruited through community-based service providers, poster media campaigns, and referrals from friends and active participants (45%, 30%, and 23%,
Participant flow and demographic characteristics of the sample
Fig. 1 shows the flow of participants through the study. Nine hundred and seventy-three participants were screened for the project over a 5-year period. Three hundred and forty-one participants met our inclusion criteria and completed the baseline assessment. Reasons for ineligibility were (in rank order): (1) had not used methamphetamine at least twice in the past 2 months and once in the past 30 days (35%); (2) had not had unprotected sex with an HIV-negative or serostatus-unknown partner in
Discussion
This study compared a theory-based behavioral intervention to a time-equivalent diet and exercise control condition on long-term improvements and maintenance of safer sex behaviors in a sample of HIV-positive methamphetamine-using MSM. We found that by the end of the active phase of the interventions (i.e., at 4 months) the two groups did not differ in their safer sex behaviors. However, by 8 months post-baseline, participants in the EDGE intervention engaged in significantly more protected sex
Acknowledgements
This research was supported by the National Institute on Drug Abuse award DA 012116.
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