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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
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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
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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
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Experimental Design
Intervention GroupIntervention GroupControl GroupControl Group
Recruitment Recruitment (Targeted Sampling in Communities of the North Health Care Region)
Initial Assessment RandomizationInitial Assessment Randomization
Follow-Up AssessmentFollow-Up Assessment
Afte
r 6
mon
ths
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
Ou
tcom
es
Ou
tcom
esIn
terv
en
tion
In
terv
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tion
P
rocess:
Pro
cess:
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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
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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 1st
session» Referral to drug treatment» Referral for health care as needed
(depending on HIV test results)
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Methods: Study Design
• The experimental arm– A two-facet intervention (based on
miller’s motivational interviewing model - MIM)
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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
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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
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Methods: Participants
• Follow-up data:– May 1999 to July 2001
• Recruitment location:– Vega Baja
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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
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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
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ER Methods: Measurement
Instruments
• Drug Use– Urinalysis to verify use of:
• Morphine• Cocaine• THC• PCP• Amphetamines
– Abuscreen OnTrack kit– Addiction Severity Index
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Methods: Analysis
Frequency distributions
Describes study sample
Bivariate analyses (used chi-squared test of homogeneity)
Compares participants in both groups across follow-up measures
Logistics regression analyses
Assess effectiveness of experimental intervention and examine two mechanisms
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Methods: Analysis
• Regression Logistics’ 4 sets– 1st: influence of the experimental
intervention in discontinuing drug injection
– 2nd, 3rd, and 4th: influence of experimental intervention in reducing needle sharing, pooling money, sharing of cotton filters
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Results Total
(n=557)Control
(n = 272)Experimental
(n = 285)
number percent number percent number percent p-value
Gender
Males 498 89.4 239 87.9 259 90.9
Females
59 10.6 33 12.1 26 9.1 0.249
Age
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
Education
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
Table 1. Description of the study sample by control and experimental groups
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Results Table 1. Description of the study sample by control and experimental groups
Total(n=557)
Control(n = 272)
Experimental (n = 285)
number percent number percent number percent p-value
HIV status
Negative 436 87.4 222 89.5 214 85.3
Positive
63 12.6 26 10.5 37 14.7 0.152
Frequency of daily injection
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
Years of drug injection
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
Previous drug treatment (ever)
No 127 22.8 51 18.8 76 26.7
Yes 429 77.2 220 81.2 209 73.3 0.034
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ResultsTable 2. Study outcome at follow-up (6 months) by control and experimental groups
Study Outcomes Control(n = 214)
Experimental(n = 226)
number percent number percent OR 95% CI p-value
Entered drug treatment
No 149 69.6 125 55.3 1.00
Yes 65 30.4 101 44.7 1.85 (1.50, 2.74) 0.002
Continued injection drug use
No 34 15.9 58 25.7 1.00
Yes 180 84.1 168 74.3 0.55 (0.34, 0.88) 0.012
Among those who continued to inject:
Shared needles
No 148 88.1 140 94.6 1.00
Yes 20 11.9 8 5.4 0.42 (0.18, 0.91) 0.042
Shared cotton
No 136 81.0 124 83.8 1.00
Yes 32 19.0 24 16.2 0.82 (0.46, 1.47) 0.511
Pooled money to buy drugs
No 58 38.2 60 43.8 1.00
Yes 94 61.8 77 56.2 0.79 (0.71, 1.12) 0.330
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Results
OR=1.95, 95% CI=1.27-2.99, p=0.002
OR=0.60, 95% CI=0.36-0.99, p=0.040
Entered drug treatment(1a)2
Continued drug injectionIntervention
OR=0.51, 95% CI=031-0.85, p=0.010
Path diagrams1 for risk of (1a) continued drug injection, (1b) needle sharing, (1c) pooling money to buy drugs,
and (1d) sharing cotton
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Path diagrams1 for risk of (1a) continued drug injection, (1b) needle sharing, (1c) pooling money to
buy drugs, and (1d) sharing cotton
OR=1.71, 95% CI=1.01-2.94, p=0.051
Increased self-efficacy
Intervention Needle sharing
(1b)3
OR=0.41, 95% CI=0.16-0.98, p=0.052
OR=0.46, 95% CI=0.15-1.47, p=0.192
Results
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Path diagrams1 for risk of (1a) continued drug injection, (1b) needle sharing, (1c) pooling money to
buy drugs, and (1d) sharing cotton
Increased self-efficacy
Intervention Pooling money to buy drugs
(1c)3
OR=0.49, 95% CI=0.29-0.80, p=0.005
OR=072, 95% CI=0.44-1.18, p=0.192
OR=1.19, 95% CI=0.73-1.94, p=0.480
Results
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Path diagrams1 for risk of (1a) continued drug injection, (1b) needle sharing, (1c) pooling
money to buy drugs, and (1d) sharing cotton
OR=1.33, 95% CI=0.82-2.17, p=0.246
Increased self-efficacy
Sharing cottonIntervention
(1d)3
OR=0.75, 95% CI=0.38-1.47, p=0.405
OR=1.10, 95% CI=0.57-2.13, p=0.764
Results
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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
