Depression and the Increased Risk of HIV / Sexually Transmitted Infections Among Substance-Using Women in the Criminal Justice System

Background and Purpose: To discuss the increased risk of HIV/STI sexual risk behaviors identified among depressed participants in the 2009 Women on the Road to Health (WORTH) HIV/STI intervention. WORTH is a group-level HIV/STI intervention designed for court-involved substance using women engaged in risky drug and sexual behaviors. The only intervention of its kind, WORTH has been added to the CDC compendium of evidence-based HIV/STI interventions. Earlier analyses of 2009 WORTH data (n=337) identified rates of HIV/STIs among Black participants (n=221) comparable to rates found in sub-Saharan Africa. Depression levels were also significantly high across participants and study arms. While WORTH is efficacious in lowering HIV/STI risks among substance-using women who have been convicted of crimes, it is not designed to treat depression.

Methods: A longitudinal secondary data analysis examining depression as a moderator on HIV/STI drug and sexual risk outcomes (main study outcomes). Depression, modeled continuously using the BSI depression sub-scale, was moderated on (1) the “intervention effect” of assignment to the active treatment conditions of the WORTH intervention (a multimedia version of the WORTH intervention or a traditional paper-based version) versus assignment to the control arm (Wellness Promotion); and (2) within those assigned to the active treatment condition, the “modality effect” of the delivery method (multimedia versus traditional). Intention-to-treat analyses were used to estimate the effects in the main study. Intervention and modality effects were obtained by applying generalized linear models with random effects for repeated measures in multiple imputed data. For the secondary data analysis, depression (baseline) was modeled against primary study outcomes obtained from self-reported HIV/STI drug and sexual risk data collected at 3-, 6- and 12-months.

Results: Depression significantly moderated sexual risk outcomes for the intervention effects model, both as a main effect and as an interaction term. Depressed, substance-using participants assigned to either intervention arm were significantly more likely to engage in risky HIV/STI sexual behaviors at the 3- and/or 6-month mark (e.g. number and proportion of unprotected vaginal and/or anal sex with primary and other sexual partners; inconsistent condom use during vaginal sex with primary partner or other sexual partners) when compared to depressed participants assigned to the control arm, thus increasing their risk for HIV/STIs. Depression did not moderate the modality effects model or substance-use risk behaviors (e.g. crack cocaine, injection drug use).

Conclusions and implications: Study findings has implications across multiple social work grand challenges given the ongoing need to “Close the Health Gap” experienced by highly vulnerable populations. Given the identified moderation between depression and HIV/STI sexual risk behaviors, and the lack of behavioral/mental health services available in low-resourced US criminal justice settings, there is a public health need to address the moderating effect of depression on HIV/STI study outcomes. Our presentation will feature a nuanced discussion regarding intervention 1) adaptation, 2) targeting, and 3) delivery to maximize HIV/STI intervention outcomes for substance-using and depressed female community corrections populations. We will also discuss the role of evidence-based interventions in addressing behavioral health risks for which they were not designed.