Multi-session motivational and behavioral training targeted specifically to men or women can cut substance abusers' high-risk sexual behaviors more effectively and enduringly than a typical single preventive educational intervention. In a large-scale test of gender-specific interventions, male participants in Real Men Are Safe (REMAS) and female participants in Safer Sex Skills Building (SSB) workshops made greater reductions in high-risk sexual behavior for a longer period than comparison groups, who were provided a standardized single-session HIV educational intervention designed to mimic those provided in many substance abuse clinics. Moreover, at the 3-month followup, men who received the training were less likely than the comparison group to have been under the influence of drugs during their most recent sexual experience.
The studies were conducted in community methadone and outpatient substance abuse treatment clinics in 10 States. All the clinics are members of NIDA's Clinical Trials Network, a partnership of academic researchers and community service providers that evaluates and adapts research-based interventions for widespread use. Staff counselors from each clinic received training by the study leaders, then delivered the interventions. "The use of staff counselors is an important aspect of these studies because it tells us that these interventions are highly feasible in real-world settings," says Dr. Susan Tross of the New York State Psychiatric Institute in New York City, who led the study of SSB.
An Agenda of Self-Protection
Prevention of sexual transmission of HIV, especially among drug-abusing populations, is a critical priority for curbing the AIDS epidemic, says Dr. Donald Calsyn of the Alcohol and Drug Abuse Institute in Seattle, Washington, leader of the REMAS study. Of an estimated 56,000 new infections in 2006, the most recent year for which figures are available, 54 percent were attributed to sexual contact between men and 31 percent to heterosexual behaviors. Drug abusers and their sexual partners are disproportionately represented among people with new HIV infections.
REMAS and SSB each consists of five 90-minute sessions that teach participants about sexual transmission of HIV and other infections, identify high-risk sexual activities, and emphasize the use of safer sex practices to protect oneself and one's partners. Participants discuss concerns that they might have about using safer sex practices and engage in role-playing exercises to sharpen their negotiation skills with partners and prospective partners.
REMAS teaches the use of assertive communication and active listening skills and emphasizes taking responsibility for protecting self and partner. SSB stresses balance between meeting relationship needs and practicing safer sex behaviors. Participants in SSB brainstorm and rehearse strategies for refusing risky sex while avoiding harm from potentially aggressive partners. "The women's intervention is oriented to communication and assertiveness and relationship skills," says Dr. Tross. "That is because, traditionally, women have not had as much power in sexual relationships as men."
Gender-Specific Programs Prove Effective
Altogether 58 percent of the men and 43 percent of the women who started the REMAS or SSB programs, respectively, completed their interventions by attending three or more sessions. Participants in both groups reduced the number of unprotected sexual intercourse occasions (USOs).
Men who completed REMAS decreased these events by 21 percent from the start of the study to the 6-month followup, while men in the single HIV informational session increased USOs by 2 percent over the same period. Among women who completed the SSB program, USOs dropped by 27 percent from the start of the trial to the 6-month followup. In contrast, women who received the single HIV informational session increased their USOs by 24 percent.
REMAS was particularly effective in inculcating condom use during sex with casual partners. The percentage of REMAS recipients reporting such use during 80 percent or more of sexual encounters increased from 4 percent before the intervention to 20 percent at the 6-month followup.
The REMAS goal of reducing men's drug use during sexual activity was achieved in the short run: Whereas prior to the intervention, 36.8 percent of REMAS recipients reported being under the influence of drugs during their most recent sexual encounter, that percentage fell to 25.7 at the 3-month followup. For men who received only the single session of HIV information, drug use rose over the same interval from 36.9 percent to 38.3 percent. After 6 months, the groups were similar with about 31 percent of each group reporting sex under drug influence during their most recent sexual event.
Says Dr. Calsyn, "We would like to see drug treatment centers start to adopt HIV-preventive interventions that are designed for substance abuse patients and go beyond the information provided in one-session interventions." "The good news is that if you can do the SSB program, you not only get immediate benefits in women avoiding unprotected sex, but the benefits can hold for at least 6 months," says Dr. Tross. "That is the great challenge for safer sex in the HIV era: You have to change the behavior not just once but for the long haul."
The Centers for Disease Control and Prevention (CDC) has placed both REMAS and SSB in its database of interventions that scientifically rigorous studies have established as being highly effective. "Being on the CDC list means that these interventions will be disseminated on a much larger scale than if they were just published in a journal article," says Dr. Jacques Normand, director of NIDA's AIDS Research Program.
"These studies are important because they tackle sexual risk behavior," says Dr. Normand. "Up until recently, HIV prevention for substance abusers concentrated on reducing injection-related risk behavior, but NIDA is now supporting studies that pay attention to sexual risk behavior in the context of substance abuse."
For detailed descriptions of the interventions and free manuals and implementation aids regarding REMAS, see ctndisseminationlibrary.org/display/397.htm; for SSB, see ctndisseminationlibrary.org/display/398.htm.
Calsyn, D.A., et al. Reducing sex under the influence of drugs or alcohol for patients in substance abuse treatment. Addiction 105(1):100–108, 2010. [Full Text (PDF, 340KB)]
Calsyn, D.A., et al. Motivational and skills training HIV/STI sexual risk reduction groups for men. Journal of Substance Abuse Treatment 37(2):138–150, 2009. [Full Text (PDF, 545KB)]
Tross, S. Effectiveness of HIV/STD sexual risk reduction groups for women in substance abuse treatment programs: Results of a NIDA Clinical Trials Network trial. Journal of Acquired Immune Deficiency Syndrome 48(5):581–589, 2008. [Full Text (PDF, 643KB)]