Reducing Sex under the Influence for Substance Abuse

Reducing Sex under the Influence for Substance Abuse Treatment Patients Symposium Presentation at the American Psychological Association Annual Convention, Boston, MA August 16, 2008

Lead Investigator: Donald A. Calsyn, Ph. D. , Alcohol & Drug Abuse Inst. , University of Washington Co-Investigators: Mary Hatch-Maillette, Ph. D. , ADAI - U of WA, Suzanne R. Doyle, Ph. D. , ADAI - U of WA, Paul Crits-Christoph, Ph. D. , U of Penn. Yong S. Song, Ph. D. , U of CA San Francisco Susan Coyer, MAC , Prestera, Hunnington, WV Sara Pelta, MA. , U of CA San Francisco Will Pescock, B. A. , COMPASS, Toledo, OH Supported by NIDA (1 U 10 DA 13714 -01, Dennis Donovan, PI)

Study Design for NIDA CTN Protocols Safe Sex for Men & Safe Sex for Women Participants • Men/Women in substance abuse treatment (16 sites) • Report unprotected vaginal or anal intercourse during the past 6 months. Interventions • Randomly assigned to either: – a standard one session HIV education intervention – 5 session gender specific HIV prevention intervention Measurement • ACASI Assessments at baseline, 3 & 6 mo. follow up • Primary outcome: number of unprotected vaginal and anal sexual intercourse occasions.

Reduction in Sexual Risk as a Function of Completing Real Men Are Safe ES=0. 213 ES=0. 337 Intervention by Time by Complete p<. 001

Secondary Outcomes Attitude towards condoms Possession of condoms Intent to use condoms Condom Use Skills Use of condoms Sex under the influence of drugs or alcohol Frequency of “outer course” Number of sexual partners

Background HIV Risk Behavior § Engaging in sex while under the influence of drugs or alcohol is common among men in substance treatment. § At baseline assessment § 71% reported some sex under the influence in past 90 days § 39 % reported sex under the influence during their most recent sexual event. § Sex under the influence is more likely to occur with a casual partner than a regular partner HIV Prevention in SA Treatment § Most HIV prevention programs encourage people not to engage in sex under the influence. § However, how to change that behavior is often not addressed outside of “just say no. ”

REMAS: Real Men are Safe Session 3 Sex without drugs. Can it happen? Is it Pleasurable? I. Welcome, redo introductions 5 Min II. Personalizing Commitment to Sexual Safety 15 Min III. Experience with combining sex & drugs Enhancements/Impairments 35 Min IV. Enhancing sex without drugs 20 Min V. Coping with sexual impairment without drugs 15 Min

Sample Demographics HIV-ED REMAS (n=199) (n=197) m Age 40. 6 Education 12. 4 Income (Mo. ) 406. 4 Marital Never Married Div/Wid/Sep (sd) (10. 4) (2. 0) (830. 7) n (%) 92 (46. 2) 33 (16. 6) 74 (37. 2) m 39. 6 12. 0 517. 2 n 94 43 60 (sd) (10. 7) (1115. 9) (%) (47. 7) (21. 8) (30. 5)

Sample Demographics Ethnicity Black White Hispanic Native Am. Asian Other Tx Modality Methadone Psychosocial HIV-ED n (%) 58 (29. 2) 118 (59. 3) 20 (10. 1) 1 (. 5) 2 (1. 0) 0 (. 0) 128 (64. 3) 71 (35. 7) REMAS n (%) 53 (24. 8) 117 (54. 7) 34 (15. 9) 5 ( 2. 3) 2 (. 9) 3 ( 1. 4) 115 82 (58. 4) (41. 6)

Data Analytic Approach Primary Outcome (dependent) Variable: Engaged in sex under the influence of drugs or alcohol during the most recent sexual event Approach: Repeated Measures Logistic Regression Model Software: SAS Logistic Procedure Independent variables used in models: Intervention Condition Time Partner Risk (casual / regular) Treatment Modality (MM / OPS) Covariate used in the model: Sex under the influence at baseline

Sex under the Influence Over Time as a Function of Intervention Condition, Partner Risk & Treatment Modality Model Results of Repeated Measures Logistic Regression Variable Parameter Standard t-value p Estimate Error Intercept -2. 75 0. 45 -6. 13 <. 001 Intervention -1. 01 0. 39 -2. 61 0. 009 Time -0. 55 0. 30 -1. 83 0. 069 Intervention by Time 0. 97 0. 45 2. 18 0. 030 Partner Risk 1. 14 0. 32 3. 50 <. 001 Tx Modality 1. 19 0. 36 3. 36 <. 001 Covariate 2. 14 0. 37 5. 74 <. 001

Change in Percentage of Men Engaging in Sex under the Influence during Last Sexual Event as a Function of Intervention Condition Intervention x Time, t=2. 18, p=0. 03 * *p=. 0065

Percentage of Men Engaging in Sex under the Influence during Last Sexual Event as a Function of Partner Risk, t=3. 50, p<. 001

Percentage of Men Engaging in Sex under the Influence during Last Sexual Event as a Function of Treatment Modality, t=3. 36, p=0. 001

Conclusions • An intensive gender specific HIV prevention intervention was associated with a reduction in sex under the influence of drugs or alcohol for men in treatment. • There was a significant difference between the interventions at 3 the month follow up, but not at 6 months. • Sex under the influence occurred more frequently with casual compared to regular partners. • Sex under the influence occurred more frequently with methadone maintenance patients compared to outpatient psychosocial program patients.

Limitations • The outcome data was self report, although social desirability was lessened with ACASI methodology. • Sample size limits power for exploring more complex interactions. • Generalizations are somewhat limited by 67% rate of completing follow up assessments • The active ingredient for the effect is unclear.

Implications • Findings point to the need for treatment programs to address the “sex under the influence” issue in treatment. • Future studies may want to explore differences noted between methadone and psychosocial program patients. • Future studies should explore if patients adopt suggestions to enhance sex without drugs made in HIV/STI prevention groups.

Special Thanks! 590 Men who participated in the CTN 0018 study 24 Regional Research Training Center Staff and CTP Principal Investigators 16 Site Coordinators 22 Research Assistants 70 Clinicians and Clinical Supervisors 32 Data Managers and Quality Assurance Monitors