HIV Prevention In Community-Based Substance Abuse Treatment: The NIDA CTN Safer Sex for Women Study

Background and Purpose: Data indicates that substance use may play a role in over 50% of HIV infections through high risk heterosexual contact, injection drug use, and in cases with combined risk (CDC, 2006). Drug-involved women are at especially high risk for heterosexual transmission of HIV, as primary male partners often use drugs and their own substance use may impair decision-making and decrease perception of risk. Brief, didactic interventions have been insufficient in reducing sexual risk behaviors. The “Safer Sex for Women Study” offered an opportunity to test a multi-session, gender-specific, efficacious treatment against a single HIV education prevention session in a large effectiveness trial. The single session was modeled on standard curriculum most commonly offered within substance abuse treatment programs (Shoptaw et al., 2002). The purpose of this presentation is to report on findings from the trial and place these findings in the context of practice and policy.

Methods: Conducted within the National Institute on Drug Abuse Clinical Trials Network (CTN), the “Safer Sex Study” enrolled 515 women from 12 community-based methadone maintenance or outpatient psychosocial treatment programs in nine states. Eligible participants reported at least one unprotected sexual occasion (USO) with a male partner in the 6 months prior to enrollment and were not pregnant or planning a pregnancy. Women were randomized to a 5-session Safer Sex Skills Building group (SSB; El-Bassel & Schilling, 1992) or a 1-session HIV Education group (HE). Participants were assessed at baseline and 3- and 6-months post treatment. Mixed effects modeling was used to test the effect of the interventions on number of USO. Two sets of secondary analyses explored the associations between childhood sexual abuse, substance use and USO at baseline and the intervention effect on substance use, injection drug use, and sex while intoxicated.

Results: The primary analysis revealed a significant time by intervention interaction whereby both interventions produced reductions in USO at 3-month follow-up, but SSB further reduced USO at 6-month follow-up while women in HE returned to baseline levels. Secondary analyses showed a significant treatment by time interaction for sex while intoxicated; participants in SSB decreased the number of sexual occasions while intoxicated over time. No differences between SSB and HE were detected for other substance use outcomes. For women with childhood sexual abuse, increases in cocaine use was associated with increases in USO, while increases in opiate use were associated with decreases in USO. Women without abuse had a significant increase in USO with increased opiate use.

Conclusions & Implications: Evidence-based HIV prevention should be integrated into substance abuse treatment programs; however, current policy limitations and practice demands make this challenging. Further, contextual factors, such as trauma history, are important to understanding sexual behaviors that increase HIV risk. Social workers are well positioned to advocate for best practices in clinical settings and for state and local policies that enhance quality of care. Thus, social workers can and should be key collaborators in the research conducted within the CTN to maximize the impact within community-based treatment settings.