CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Effects of a Two-facet Intervention to Reduce HIV Risk Behaviors Among Hispanic Drug Injectors in Puerto Rico: A Randomized Controlled Study Robles RR, Reyes JC, Colon HM, Sahai H, Marrero CA, Matos TD, Calderon JM, Shepard E
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER The Objective • Test the effectiveness of combining counseling and case management behavioral intervention, using motivational interviewing strategies to: – Engage IDUs in drug treatment and health care – Enhance their self-efficacy – Help them reduce HIV risk behaviors
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER The Hypothesis • Engaging IDUs in drug treatment and enhancing their self-efficacy would predict favorable study outcomes – Participants in the experimental group would perform better than the control group on outcome measures – Those who engaged in drug treatment would perform better than those who did not engage in drug treatment; And – Participants who increased their self-efficacy would perform better on outcomes than those who did not increase their self efficacy
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Experimental Design
Recruitment (Targeted Sampling in Communities of the North Health Care Region) Initial Assessment Randomization Intervention Group Motivational Interviewing by Outreach Workers • Inducement to Enter Change Process Motivational Interviewing by Clinical Counselors • Skill Building to Change Risk Behaviors • Inducement to Enter Treatment and Health Care Follow-Up Assessment Outcomes After 6 months Intervention Process: Control Group
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Study Design • The control arm – All subjects participated in control intervention based on CDC protocol • Two one-on-one sessions with a RN – First session included: » Discussion of HIV/AIDS as a disease » Discussion and practice of safe needle use and safe sex skills » Discussion of HIV testing and option to test » HIV testing to those consenting to be tested » Invitation to return to the site for HIV results
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Study Design • The control arm – All subjects participated in control intervention based on CDC protocol • Two one-on-one sessions with a RN – Second session included: » Posttest counseling » Review of information provided in 1 st session » Referral to drug treatment » Referral for health care as needed (depending on HIV test results)
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Study Design • The experimental arm – A two-facet intervention (based on miller’s motivational interviewing model - MIM)
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Study Design • The experimental arm – Participants were offered: • Six counseling sessions • Active assistance from a case manager in helping them address any problems such as: – Impediments to participate in or complete the intervention – Accessing drug treatment, primary health care services – Accessing services such as: » Housing » Social welfare » Legal assistance
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Participants • Recruitment goal: – Enroll a sample of drug injectors • 18 to 65 yrs old • Not in treatment • Recruitment timeframe: – November 1998 to January 2001
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Participants • Follow-up data: – May 1999 to July 2001 • Recruitment location: – Vega Baja
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Participants • Eligibility determined by: – Injected during the past 30 days – Age: 18 yrs. Or older – Ability to communicate – Consent – Urinalysis to confirm recent use of cocaine or heroine
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Data Collection • Instruments – Baseline assessment • • • Drug use patterns HIV risk behaviors Sociodemographics History of drug treatment and health care use Family embeddedness and support Psychological and health status – Follow-up assessment • 79. 1% were re-contacted and interviewed • Similar instrument to baseline
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Measurement Instruments • Drug Use – Urinalysis to verify use of: • • • Morphine Cocaine THC PCP Amphetamines – Abuscreen On. Track kit – Addiction Severity Index
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Analysis Frequency distributions Describes study sample Bivariate analyses (used chi-squared test of homogeneity) Compares participants in both groups across followup measures Logistics regression analyses Assess effectiveness of experimental intervention and examine two mechanisms
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Analysis • Regression Logistics’ 4 sets – 1 st: influence of the experimental intervention in discontinuing drug injection – 2 nd, 3 rd, and 4 th: influence of experimental intervention in reducing needle sharing, pooling money, sharing of cotton filters
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Results Table 1. Description of the study sample by control and experimental groups Total (n=557) Control (n = 272) Experimental (n = 285) number percent p-value Males 498 89. 4 239 87. 9 259 90. 9 Females 59 10. 6 33 12. 1 26 9. 1 0. 249 Less than 25 years 186 34. 4 90 34. 6 96 34. 2 25 -34 years old 198 36. 6 101 38. 8 97 34. 5 35 years old or more 157 29. 0 69 26. 5 88 31. 3 0. 415 Less than high school 317 56. 9 156 57. 4 161 56. 5 High school 176 31. 6 90 33. 1 86 30. 2 More than high school 64 11. 5 26 9. 6 38 13. 3 0. 347 Gender Age Education
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Results Table 1. Description of the study sample by control and experimental groups Total (n=557) number HIV status Control (n = 272) percent number Experimental (n = 285) percent p-value number Negative 436 87. 4 222 89. 5 214 85. 3 Positive 63 12. 6 26 10. 5 37 14. 7 0. 152 0 -2 times 203 36. 6 97 35. 9 106 37. 2 3 or more times 352 63. 4 173 64. 1 179 62. 8 0. 757 0 -5 years 314 56. 4 159 58. 5 155 54. 4 6 -10 years 85 15. 3 44 16. 2 41 14. 4 11 -15 years 60 10. 8 29 10. 7 31 10. 9 16 years or more 98 17. 6 40 14. 7 58 20. 4 0. 358 No 127 22. 8 51 18. 8 76 26. 7 Yes 429 77. 2 220 81. 2 209 73. 3 0. 034 Frequency of daily injection Years of drug injection Previous drug treatment (ever)
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Table 2. Study outcome at follow-up (6 months) by control and experimental groups Results Control (n = 214) Study Outcomes number percent Entered drug treatment Experimental (n = 226) number percent OR 95% CI No 149 69. 6 125 55. 3 1. 00 Yes 65 30. 4 101 44. 7 1. 85 Continued injection drug use p-value (1. 50, 2. 74) 0. 002 No 34 15. 9 58 25. 7 1. 00 Yes 180 84. 1 168 74. 3 0. 55 148 88. 1 140 94. 6 1. 00 20 11. 9 8 5. 4 0. 42 No 136 81. 0 124 Yes 32 19. 0 No Yes Among those who continued to inject: Shared needles No Yes Shared cotton Pooled money to buy drugs (0. 34, 0. 88) 0. 012 (0. 18, 0. 91) 0. 042 83. 8 1. 00 24 16. 2 0. 82 58 38. 2 60 43. 8 1. 00 94 61. 8 77 56. 2 0. 79 (0. 46, 1. 47) 0. 511 (0. 71, 1. 12) 0. 330
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Results Path diagrams 1 for risk of (1 a) continued drug injection, (1 b) needle sharing, (1 c) pooling money to buy drugs, and (1 d) sharing cotton (1 a)2 Entered drug treatment OR=1. 95, 95% CI=1. 27 -2. 99, p=0. 002 OR=0. 51, 95% CI=031 -0. 85, p=0. 010 Intervention Continued drug injection OR=0. 60, 95% CI=0. 36 -0. 99, p=0. 040
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Results Path diagrams 1 for risk of (1 a) continued drug injection, (1 b) needle sharing, (1 c) pooling money to buy drugs, and (1 d) sharing cotton (1 b)3 Increased self-efficacy OR=1. 71, 95% CI=1. 01 -2. 94, p=0. 051 OR=0. 46, 95% CI=0. 15 -1. 47, p=0. 192 Intervention Needle sharing OR=0. 41, 95% CI=0. 16 -0. 98, p=0. 052
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Results Path diagrams 1 for risk of (1 a) continued drug injection, (1 b) needle sharing, (1 c) pooling money to buy drugs, and (1 d) sharing cotton (1 c)3 Increased self-efficacy OR=1. 19, 95% CI=0. 73 -1. 94, p=0. 480 OR=0. 49, 95% CI=0. 29 -0. 80, p=0. 005 Pooling money to buy drugs Intervention OR=072, 95% CI=0. 44 -1. 18, p=0. 192
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Results Path diagrams 1 for risk of (1 a) continued drug injection, (1 b) needle sharing, (1 c) pooling money to buy drugs, and (1 d) sharing cotton (1 d)3 Increased self-efficacy OR=0. 75, 95% CI=0. 38 -1. 47, p=0. 405 OR=1. 33, 95% CI=0. 82 -2. 17, p=0. 246 Intervention Sharing cotton OR=1. 10, 95% CI=0. 57 -2. 13, p=0. 764
CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Conclusions • Six-session interventions using MIM strategies in conjunction with case management techniques proved effective in helping participants: – Enter drug treatment – Discontinue drug injection (directly associated with intervention) – Reduce needle sharing
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