Roger A. Roffman

Randomised, controlled, community-level HIV-prevention intervention for sexual-risk behaviour among homosexual men in US cities

BACKGROUND Community-level interventions may be helpful in population-focused HIV prevention. If members of populations at risk of HIV infection who are popular with other members can be engaged to advocate the benefits of behaviour change to peers, decreases in risk behaviour may be possible. We assessed a community-level intervention to lower the risk of HIV infection, focusing on men patronising gay bars in eight small US cities. METHODS We used a randomised community-level field design. Four cities received the intervention and four control cities did not. Participants were men from each city who went to gay bars. Men completed surveys about their sexual behaviour on entering the bars during 3-night periods at baseline and at 1-year follow-up. In the control cities, HIV educational materials were placed in the bars. In the intervention cities, we recruited popular homosexual men in the community and trained them to spread behaviour-change endorsements and recommendations to their peers through conversation. FINDINGS Population-level of risk behaviour decreased significantly in the intervention cities compared with the control cities at 1-year follow-up, after exclusion of surveys completed by transients and men with exclusive sexual partners in a city-level analysis, in the intervention cities we found a reduction in the mean frequency of unprotected anal intercourse during the previous 2 months (baseline 1.68 occasions; follow-up 0.59: p = 0.04) and an increase in the mean percentage of occasions of anal intercourse protected by condoms (baseline 44.7%; follow-up 66.8%, p = 0.02). Increased numbers of condoms taken from dispensers in intervention-city bars corroborated risk-behaviour self-reports. INTERPRETATION Popular and well-liked members of a community who systematically endorse and recommend risk-reduction behaviour can influence the sexual-risk practices of others in their social networks. Natural styles of communication, such as conversations, brought about population-level changes in risk behaviour.

Outcomes of a randomized community-level HIV prevention intervention for women living in 18 low-income housing developments

OBJECTIVES Women in impoverished inner-city neighborhoods are at high risk for contracting HIV. A randomized, multisite community-level HIV prevention trial was undertaken with women living in 18 low-income housing developments in 5 US cities. METHODS Baseline and 12-month follow-up population risk characteristics were assessed by surveying 690 women at both time points. In the 9 intervention condition housing developments, a community-level intervention was undertaken that included HIV risk reduction workshops and community HIV prevention events implemented by women who were popular opinion leaders among their peers. RESULTS The proportion of women in the intervention developments who had any unprotected intercourse in the past 2 months declined from 50% to 37.6%, and the percentage of womens acts of intercourse protected by condoms increased from 30.2% to 47.2%. Among women exposed to intervention activities, the mean frequency of unprotected acts of intercourse in the past 2 months tended to be lower at follow-up (mean = 4.0) than at baseline (mean = 6.0). These changes were corroborated by changes in other risk indicators. CONCLUSIONS Community-level interventions that involve and engage women in neighborhood-based HIV prevention activities can bring about reductions in high-risk sexual behaviors.

A randomized controlled trial of brief cognitive-behavioral interventions for cannabis use disorder.

The increasing demand for treatment for cannabis dependence in Australia and internationally has led to the identification of significant gaps in knowledge of effective interventions. A randomized controlled trial of brief cognitive-behavioral interventions (CBT) for cannabis dependence was undertaken to address this issue. A total of 229 participants were assessed and randomly assigned to either a six-session CBT program (6CBT), a single-session CBT intervention (1CBT), or a delayed-treatment control (DTC) group. Participants were assisted in acquiring skills to promote cannabis cessation and maintenance of abstinence. Participants were followed-up a median of 237 days after last attendance. Participants in the treatment groups reported better treatment outcomes than the DTC group. They were more likely to report abstinence, were significantly less concerned about their control over cannabis use, and reported significantly fewer cannabis-related problems than those in the DTC group. Those in the 6CBT group also reported more significantly reduced levels of cannabis consumption than the DTC group. While the therapist variable had no effect on any outcome, a secondary analysis of the 6CBT and 1CBT groups showed that treatment compliance was significantly associated with decreased dependence and cannabis-related problems. This study supports the attractiveness and effectiveness of individual CBT interventions for cannabis use disorders and the need for multisite replication trials.

Treating adult marijuana dependence: a test of the relapse prevention model.

Men (n = 161) and women (n = 51) seeking treatment for marijuana use were randomly assigned to either a relapse prevention (RP; G.A. Marlatt & J.R. Gordon, 1985) or a social support (SSP) group discussion intervention. Data collected for 12 months posttreatment revealed substantial reductions in frequency of marijuana use and associated problems. There were no significant differences between the cognitive-behavioral RP intervention and the SSP group discussion conditions on measures of days of marijuana use, related problems, or abstinence rates. Men in the RP condition were more likely than men in the SSP condition to report reduced use without problems at 3-month follow-up. Posttreatment increases in problems associated with alcohol did not appear to relate to reduced marijuana use. Results are discussed in terms of the need for further research with marijuana-dependent adults and the efficacy of RP.

Adult Marijuana Users Seeking Treatment.

In an effort to study the efficacy of attracting and intervening with adult marijuana users, 290 men and 92 women were screened for participation in a treatment-outcome study focused on marijuana cessation. The well-educated, self-referred sample reported using marijuana on 79 of the past 90 days before testing. Indices of the severity of marijuana abuse and general psychopathology were in the clinical range for a majority of Ss. Ss who did not report evidence of alcohol or other drug abuse (n = 144) reported less severe consequences of marijuana use and experienced less general psychological distress than Ss who also reported lifetime (n = 165) or current abuse (n = 73) of other substances in addition to marijuana. The findings indicate the need for clinical research targeting adults who are dependent on marijuana.

Outcomes of a randomized, controlled community-level HIV prevention intervention for adolescents in low-income housing developments.

Objectives:Youth are increasingly at risk for contracting HIV infection, and community-level interventions are needed to reduce behavioral risk. Design:A randomized, controlled, multi-site community-level intervention trial was undertaken with adolescents living in 15 low-income housing developments in five US cities. Methods:Baseline (n = 1172), short-term follow-up (n = 865), and long-term follow-up (n = 763) risk assessments were conducted among adolescents, ages 12–17, in all 15 housing developments. The developments were randomly assigned in equal numbers to each of three conditions: experimental community-level intervention (five developments); ‘state-of-the-science’ skills training workshops (five developments); and, education-only delayed control intervention (five developments). Results:At long-term follow-up, adolescents living in the housing developments receiving the community-level intervention were more likely to delay onset of first intercourse (85%) than those in the control developments (76%), while those in the workshop developments (78%) did not differ from control condition adolescents. Adolescents in both the community-level intervention (77%) and workshop (76%) developments were more likely to use a condom at last intercourse than those in control (62%) developments. Conclusions:Community-level interventions that include skills training and engage adolescents in neighborhood-based HIV prevention activities can produce and maintain reductions in sexual risk behavior, including delaying sexual debut and increasing condom use.

Factors Predicting Continued High-Risk Behavior among Gay Men in Small Cities: Psychological, Behavioral, and Demographic Characteristics Related to Unsafe Sex.

Nearly 6,000 men entering gay bars in 16 small American cities were anonymously surveyed to assess their sexual behavior and to determine predictors of risky sexual practices. Excluding individuals in long-term exclusive relationships, 27% of the men reported engaging in unprotected anal intercourse in the past 2 months. Factors strongly predictive of risk included having a large number of different male partners, estimating oneself to be at greater risk, having weak intentions to use condoms at next intercourse, believing that safer sex is not an expected norm within ones peer reference group, being of younger age, and having less education. These findings indicate that HIV prevention efforts are urgently needed for gay men in smaller cities, with efforts particularly focused on young and less educated men sexually active with multiple partners. Prevention should focus on strengthening intentions to change behavior and on changing social norms to foster safer sex.

A Telephone Based Brief Intervention Using Motivational Enhancement to Facilitate HIV Risk Reduction Among MSM: A Pilot Study

We conducted a randomized controlled pilot intervention to evaluate the efficacy of a telephone-based brief counseling intervention to reduce sexual risk taking among men who have sex with men (MSM) in Seattle, Washington. The study targeted individuals who were currently engaging in unsafe sex but were not committed to making changes toward safer behaviors. Counselors used motivational interviewing strategies in a single 90-min session to enhance readiness for change, promote greater intentions to use condoms, and to support safer sex practices. Results are based on 89 MSM randomly assigned to Immediate counseling or a Delayed counseling control condition. Among minority participants, Immediates were significantly less likely to have engaged in unprotected anal intercourse at follow-up, compared to Delays. Immediate participants reported significantly less ambivalence about practicing safer sex at follow-up, and tended to report greater increases in intentions to use condoms. These findings support the potential efficacy of a brief intervention based upon motivational enhancement principles for promoting safer sex practices among at-risk MSM.

RISK FOR HIV INFECTION AMONG BISEXUAL MEN SEEKING HIV-PREVENTION SERVICES AND RISKS POSED TO THEIR FEMALE PARTNERS

The present study interviewed gay (n = 473) and bisexual men (n = 146) as part of an HIV prevention program and investigated social cognitive factors associated with HIV risk. Results indicated that HIV risk in homosexual men was associated with sexual openness and connections to gay communities, factors not associated with risk for bisexual men. Compared with men at lower risk, those who practiced high-risk sex scored lower on measures of perceived safer sex norms, safer sex self-efficacy, and social skills. Bisexual men with primary female partners often had not disclosed their bisexuality to female partners (75%), and 64% had not modified their behavior to protect female partners. Bisexual men who engage in high-risk behaviors therefore pose a risk to female partners who may be unaware of their involvement with men.

Motivation to Reduce HIV Risk Behaviors in the Context of the Information, Motivation and Behavioral Skills (IMB) Model of HIV Prevention:

The Information-Motivation-Behavioral Skills (IMB) model of health behavior was tested in a sample of 391 men who have sex with men at high-risk for HIV transmission. Prospective analyses of IMB predictors of unprotected anal intercourse (UAI) confirmed a good fit. Self-rated motivation was a significant predictor of UAI, as were behavioral skills. However, the lack of information and motivational constructs that predicted behavior suggests that the IMB model is limited as a theory and has its greatest utility as a framework for guiding HIV risk reduction interventions for men who have sex with men at high-risk for HIV infection.