1. 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

2. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER 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

3. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER 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

4. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Experimental Design

5. Intervention Group Control Group Recruitment (Targeted Sampling in Communities of the North Health Care Region) Initial Assessment Randomization Follow-Up Assessment After 6 months 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 Outcomes Intervention Process:

6. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER 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

7. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER 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 1 st session »Referral to drug treatment »Referral for health care as needed (depending on HIV test results)

8. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Study Design The experimental arm –A two-facet intervention (based on miller’s motivational interviewing model - MIM)

9. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER 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

10. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER 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

11. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Participants Follow-up data: –May 1999 to July 2001 Recruitment location: –Vega Baja

12. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER 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

13. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER 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

14. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Measurement Instruments Drug Use –Urinalysis to verify use of: Morphine Cocaine THC PCP Amphetamines –Abuscreen OnTrack kit –Addiction Severity Index

15. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER 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

16. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Methods: Analysis Regression Logistics’ 4 sets –1 st : influence of the experimental intervention in discontinuing drug injection –2 nd, 3 rd, and 4 th : influence of experimental intervention in reducing needle sharing, pooling money, sharing of cotton filters

17. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Results Total (n=557) Control (n = 272) Experimental (n = 285) number percent number percent number percentp-value Gender Males49889.423987.925990.9 Females 5910.63312.1269.10.249 Age Less than 25 years18634.49034.69634.2 25-34 years old19836.610138.89734.5 35 years old or more 15729.06926.58831.30.415 Education Less than high school31756.915657.416156.5 High school17631.69033.18630.2 More than high school 6411.5269.63813.30.347 Table 1. Description of the study sample by control and experimental groups

18. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER 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 percentp-value HIV status Negative43687.422289.521485.3 Positive 6312.62610.53714.70.152 Frequency of daily injection 0-2 times20336.69735.910637.2 3 or more times 35263.417364.117962.80.757 Years of drug injection 0-5 years31456.415958.515554.4 6-10 years8515.34416.24114.4 11-15 years6010.82910.73110.9 16 years or more 9817.64014.75820.40.358 Previous drug treatment (ever) No12722.85118.87626.7 Yes42977.222081.220973.30.034

19. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Results Table 2. Study outcome at follow-up (6 months) by control and experimental groups Study Outcomes Control (n = 214) Experimental (n = 226) numberpercentnumberpercentOR95% CIp-value Entered drug treatment No14969.612555.31.00 Yes6530.410144.71.85(1.50, 2.74) 0.002 Continued injection drug use No3415.95825.71.00 Yes18084.116874.30.55(0.34, 0.88)0.012 Among those who continued to inject: Shared needles No14888.114094.61.00 Yes2011.985.40.42(0.18, 0.91)0.042 Shared cotton No13681.012483.81.00 Yes3219.02416.20.82(0.46, 1.47)0.511 Pooled money to buy drugs No5838.26043.81.00 Yes9461.87756.20.79(0.71, 1.12)0.330

20. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER 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 injection Intervention OR=0.51, 95% CI=031-0.85, p=0.010 Path diagrams 1 for risk of (1a) continued drug injection, (1b) needle sharing, (1c) pooling money to buy drugs, and (1d) sharing cotton

21. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Path diagrams 1 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 InterventionNeedle 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

22. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Path diagrams 1 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

23. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER Path diagrams 1 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

24. CARIBBEAN BASIN AND HISPANIC ADDICTION TECHNOLOGY TRANSFER CENTER 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