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Semaan S., Neumann M.S., Hutchins K. et al.
Drug and Alcohol Dependence: 2010, 106, p. 7–15.
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Across this large US study, injectors responded to sexual risk-reduction counselling as well as non-injectors; the evidence was there a year later in fewer infections. But why was what should have been the strongest intervention actually the weakest among this group, yet not among non-injectors?
Summary This is a follow-on report from a study conducted in the USA in the mid-90s which recruited over 5000 HIV-negative women and homosexual men who came for a full examination at clinics for sexually transmitted diseases. It assesses whether the injectors among them reduced their infection risk behaviour and risk of sexually transmitted infection after counselling as much as the non-injectors, and whether these results remain relevant to today's US injectors.
All the patients were randomly assigned to one of three counselling interventions intended to prevent infection with HIV and other sexually transmitted diseases, primarily by encouraging condom use. The most basic – standard at such clinics at the time – was a few minutes in each of two sessions advising the patient how to avoid infection given their risk profile. The other two interventions were more interactive and differed mainly in duration; the briefer was conducted over two sessions of 20 minutes, the enhanced version over four sessions lasting over three hours. Both involved agreeing small, personalised risk-reduction changes which could be achieved before the next session, reviewing these, and agreeing a longer-term risk-reduction plan.
An earlier report established that relative to standard advice and across all the patients, both the more interactive interventions led to greater reductions in sexual risktaking up to six months later (but not at nine and 12 months), and that over the 12 months of the follow-up, these patients also acquired fewer sexually transmitted diseases. The longer of the two interactive interventions was not significantly more effective than the brief version.
Another previous report established that relative to standard advice, among patients who admitted to ever injecting a drug, the briefer of the two interactive interventions had been just as effective Though perhaps because there were few injectors the advantage gained by interactive counselling was not statistically significant. at preventing infection as among non-injectors; the featured report calculated that after a year both groups were about 20% less likely to have become newly infected. However, among injectors, on average the enhanced four-session counselling was actually followed by non-significantly more new infections than after standard advice, and (this result too was non-significant, but only narrowly) nearly four times more than after brief interactive counselling. This did not happen among non-injectors generally, but a similar finding emerged among patients who had traded sex.
The featured report adds that patients who admitted ever injecting were just as likely to complete all their allotted intervention sessions (over 80% did so) as other patients, and that across all the interventions they substantially reduced their risk of infection by having fewer sex partners than at baseline and nearly half the number of unprotected sex episodes. Also reduced were the proportions who had recently been paid or given drugs for sex, or had sex or unprotected sex while intoxicated. These changes seemed reflected in a substantial reduction in the proportion of ever-injecting patients who 12 months later had bacterial infections, down from 19% to 7%, similar to that seen among non-injectors.
The RESPECT study found that patients who had ever injected drugs responded to personalised brief counselling by reducing their sexual risk behaviours, resulting in fewer sexually transmitted bacterial infections. These results show the potential long-term efficacy of the two-session intervention among drug users in reducing unprotected sex, number of sex partners, trading sex, having sex while high on alcohol or drugs, and having unprotected sex while high, and suggest that its impacts are as great as among non-injectors. The levels of sexual activity and sexually transmitted infections among RESPECT's injector sample refute the assumption that drug users do not have sex. Present day drug users have a similar infection profile to RESPECT's injectors, suggesting that the study's brief counselling intervention may still be relevant and effective.
commentary The featured report focused on the two-session intervention which was more effective than a few minutes of standard advice whether or not the recipient had injected drugs at some time in the past, indicating that even relatively brief personalised counselling can reduce both drug-related and sex-related risks of infection. It remains to be explained why a longer but otherwise similar intervention seemed no more or perhaps less effective than standard advice, and nearly met conventional criteria for being significantly less effective than the briefer version. A similarly counter-intuitive finding among patients who had ever been paid or given drugs for sex cannot it seems be fully explained by the minor overlap The featured report says that at the start of the study 35% of the injectors had been paid or given drugs for sex. between these categories.
It seems possible that standard advice was easily dismissed because after coming to be tested and perhaps expecting bad news given their risk profile, most found they did not have a sexually transmitted disease. It is harder to explain why the longer intervention was less effective. Two recent reviews (details below) suggest that extended interventions which embrace both drug- and sex-related risk reduction are not generally counterproductive among injectors, though also that on average they are little better than briefer interventions. It could be that an extended focus on sexual risk seems inappropriate and is reacted against by injectors, but this would not explain why a similar reaction was seen among people who traded sex. It is also possible, as the authors of the relevant report suggest, that these non-significant results were random fluctuations. On balance it would seem advisable to consider sexual as well as drug-related risk in counselling, but to be cautious about imposing unasked for extended sexual risk reduction training on injectors.
What seems to have been the most recent meta-analytic review covering sexual risk reduction among drug users found that in response to educational and skills training sessions on HIV risk reduction, on average injectors increased their condom use and decreased the frequency with which they traded sex for drugs. The interventions were generally compared with briefer and/or purely educational sessions and on average occupied eight sessions each lasting nearly an hour and a half. This suggests that, contrary to the featured study, extended intervention is preferable, but results were highly variable; several studies also found the counterproductive impact of longer intervention seen in the featured study.
The results of an earlier meta-analysis A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. suggested that some of the difference between studies (at least of HIV-negative injectors) depended on whether the focal intervention was compared to an alternative (in which case there was on average little difference in effectiveness) or to no intervention at all (in which there was a substantial reduction in risk from the intervention). The experts who reviewed these and other findings concluded that evidence was strongest for interventions which offered education about infection risk, training in how to reduce risk and improve communication and social skills, treatment both of drug problems and sexual disease, and measures to bolster social support for less risky behaviour.
Both these reviews evaluated mainly joint drug and sex risk reduction interventions, not the sex-focused intervention trialled in the featured study.
Thanks for their comments on this entry to Salaam Semaan of the US Centers for Disease Control and Prevention and other authors of the study. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 02 August 2011. First uploaded
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