Brief counseling for reducing sexual risk and bacterial STIs among drug users—Results from project RESPECT

https://doi.org/10.1016/j.drugalcdep.2009.07.015Get rights and content

Abstract

Objective

Project RESPECT's brief risk reduction counseling (BRRC) reduced sexual risk and bacterial STIs among at-risk heterosexuals and has been packaged for use with this population. We assessed BRRC's efficacy with RESPECT participants who used drugs and examined BRRC's applicability to present-day users of heroin, cocaine, speedball, or crack.

Methods

We compared baseline demographic and economic variables, risk behaviors, and prevalence and correlates of bacterial STIs for ever-injectors ([EIs], N = 335) and never-injectors ([NIs], N = 3963). We assessed changes in risk behaviors and bacterial STIs for EIs and NIs at 12 months. We compared prevalence of HSV-2, hepatitis B core antigen virus (HBV), hepatitis C virus (HCV), and trichomonas among EIs with recently reported rates among drug users.

Results

At baseline, 19% of EIs and 29% of NIs had bacterial STIs. Both groups had similar baseline STI correlates. At 12 months, 4% of EIs and 7% of NIs had bacterial STIs. Twelve-month cumulative incidence of bacterial STIs in BRRC was 21% lower among EIs and 18% lower among NIs compared to the informational condition. At 12 months, EIs reported fewer sexual risk behaviors than at baseline. Baseline positivity rates of trichomoniasis in EIs (female: 15%) and in male and female EIs of HSV-2 (39%, 68%), HBV (41%, 37%), and HCV (60%, 58%) were similar to rates in present-day drug users.

Conclusion

Efficacy of BRRC in reducing sexual risk and bacterial STIs in EIs, and similar profiles for EIs and present-day drug users suggest evaluating BRRC with present-day drug users.

Introduction

Present-day drug users, whom we define as users of heroin, cocaine, speedball (a mix of heroin and cocaine), or crack have moderate rates of sexually transmitted infections (STIs) (Des Jarlais and Semaan, 2008a, Des Jarlais and Semaan, 2008b). However, the literature on reducing STIs among drug users is sparse (Semaan et al., 2007), apparently because of misconceptions that drug users are noncompliant with research protocols, prevention interventions, or medical regimens; have low STI rates; or are not sexually active (Centers for Disease Control and Prevention, 2008a, Malta et al., 2008, Wood et al., 2008). These misconceptions are not supported by the HIV literature (Centers for Disease Control and Prevention, 2008b, Des Jarlais and Semaan, 2008a, Des Jarlais and Semaan, 2008b). In fact, HIV rates among injection drug users (IDUs) have decreased during the past two decades because IDUs have lowered their parenteral risk (Centers for Disease Control and Prevention, 2008a, Des Jarlais and Semaan, 2008a, Des Jarlais and Semaan, 2008b). As a result, sexual transmission has emerged as a noteworthy source of HIV infection among IDUs and non-injection drug users who inhale, sniff, or smoke illicit drugs (Des Jarlais et al., 2007a, Des Jarlais et al., 2007b, Des Jarlais et al., 2005, Kral et al., 2001, Semaan et al., 2006, Strathdee et al., 2001). Sexual transmission of HIV is also facilitated by the presence of STIs (Fleming and Wasserheit, 1999). Yet, evaluation of research-based interventions for preventing sexual risk behaviors and bacterial STIs among drug users has received less attention than interventions for reducing HIV risk from drug use (Semaan et al., 2007).

We sought to identify existing interventions with potential for reducing sexual risk and bacterial STIs among drug users. One such intervention is the brief risk reduction counseling (BRRC) evaluated in Project RESPECT (Kamb et al., 1998). RESPECT's BRRC is one of the packaged interventions disseminated by the Diffusion of Effective Behavioral Interventions project and has been recommended for heterosexuals at high risk for STIs (Centers for Disease Control and Prevention, n.d., Centers for Disease Control and Prevention, 2008c, Kegeles et al., 2000).

We tested the applicability of RESPECT BRRC as an intervention to reduce sexual risk behaviors and bacterial STIs among present-day drug users by analyzing data from RESPECT participants with and without a history of injection drug use [ever-injectors (EIs) vs. never-injectors (NIs)]. We compared those results with the literature on present-day drug users. Data from RESPECT are relevant for several reasons. First, RESPECT was one of the few intervention studies that included EIs and NIs, allowing comparison of these two groups with data from the same project. Second, RESPECT had behavioral and biologic data, allowing for stronger conclusions on intervention efficacy. The diagnoses of bacterial STIs (i.e., gonorrhea, chlamydia, syphilis) and HIV infection were confirmed by laboratory testing. Third, few research interventions have aimed to reduce sexual risk behaviors and bacterial STIs of drug users. Fourth, behavioral and biologic data collected over 12 months help to explain the long-term efficacy of RESPECT BRRC. Finally, recent publications from Project RESPECT continue to provide relevant input for public health (Gottlieb et al., 2004, Thompson et al., 2004, Warner et al., 2004, Warner et al., 2008a, Warner et al., 2008b). Thus, knowing how EIs in RESPECT compare to present-day drug users can guide prevention providers in implementing the already packaged BRRC.

To evaluate the applicability of BRRC for present-day drug users, we assessed three questions. First, how did RESPECT's EIs and NIs, differ, and how did subgroups of EIs vary? Second, were EIs and NIs equally likely to complete the BRRC intervention and provide data at 12 months? Third, how were EIs similar to present-day drug users? The first question is important because RESPECT collected a few variables on drug use and drug risk behaviors. The subgroup analyses are particularly relevant because project RESPECT did not collect data on an adequate number of variables to describe the illicit drug use of participants. The subgroup comparisons allowed us to conjecture which drugs might have been used by EIs and NIs. The second question is relevant because little is known about drug users’ completion of sexual prevention interventions and efficacy of such interventions with drug users. The third question is germane because few interventions address bacterial STIs among drug users.

Section snippets

Study design, setting, and interventions

Details about Project RESPECT are reported elsewhere (Bolu et al., 2004, Kamb et al., 1996, Kamb et al., 1998, Peterman et al., 2000). Briefly, this multicenter, randomized, controlled trial (July 1993 to September 1996) evaluated the efficacy of HIV prevention counseling interventions in reducing sexual risk behaviors and incident STIs. HIV-negative sexually active heterosexual adults from five public STD clinics (i.e., Baltimore, MD; Denver, CO; Long Beach, CA; Newark, NJ; and San Francisco,

Baseline comparisons of EIs and NIs

In terms of demographic and economic variables, at baseline, equal percentages of EIs and NIs were male, had less than a high school education, and had an annual income below $10,000. However, EIs were older; white; unemployed; and had ever been, or had a partner who had been, in jail (Table 1). In terms of past risk behaviors, EIs reported a younger age at first sex, higher lifetime number of sex partners, ever receiving money or drugs for sex, and ever having had an HIV test (prior to the one

Summary and implications of results

Our analyses of how EIs differed from NIs in Project RESPECT, including subgroup analyses of EIs by recency of injection (past 3 months), and subgroup analyses of EIs and NIs by HCV infection, showed that at baseline, EIs were different from NIs on a few demographic and economic variables and reported higher sexual risk and drug-related sexual risk behaviors. In addition, EIs differed from NIs on rates of infection with bacterial STIs, HSV-2, HBV, and HCV. Our analyses showed that NIs engaged

Conclusion

Rates of bacterial STIs and risky sexual behaviors are high among drug users, as reported by Project RESPECT, other studies, and systematic reviews. The profile of EIs in RESPECT is not different from that of present-day users of heroin, cocaine, crack, and speedball. Compared to informational messages, RESPECT's BRRC was efficacious at reducing risky sexual behaviors and bacterial STIs among EIs and was equally efficacious for EIs and NIs. Our results suggest evaluating the BRRC package in

Role of funding source

The Centers for Disease Control and Prevention funded the parent study Project RESPECT. This paper is based on secondary data analysis from the parent project. The findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Contributors

Dr. Salaam Semaan led the design and analysis for this paper and drafted the manuscript. Ms. Kathleen Hutchins conducted the computer analysis. All authors contributed to the intellectual content of the paper, read and edited all drafts, and approved the final manuscript.

Conflict of interest

Authors Semaan, Neumann, Hutchins, and Kamb are employed by the Centers for Disease Control and Prevention.

Drs. D’Anna and Kamb are listed as part of Project RESPECT Study Group.

Acknowledgments

The authors thank Dr. Wayne D. Johnson, CDC, Atlanta, GA for statistical review and feedback, and Dr. Don C. Des Jarlais, Beth Israel Medical Center, NY, NY, and Dr. Thomas Peterman, CDC, Atlanta, GA for technical review and feedback. No compensation was provided to or received for any contribution made by these reviewers.

Project RESPECT Study Group Members: Baltimore, MD: Carolyn Erwin-Johnson, MA; Andrew L. Lentz, MPA; Mary A. Staat, MD, MPH; Dawn Sweet, PhD; and Jonathan M. Zenilman, MD

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    Project RESPECT Group members are listed in the Acknowledgments section.

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