HIV risk reduction for substance using gay and bisexual men: A harm reduction approach using group based motivational interviewing

Research Team

• Tim Guimond, CAMH • Carol Strike, CAMH • David Brennan, U of T • James Murray, AIDS Bureau • Jean Pierre Londono Sanchez, CAMH • Jim Cullen, CAMH • Karen de Prinse, Casey House • Kenneth Tong, Community • Le-Ann Dolan, ACT • Mark Hallman, SMH • Maureen Mahan, Casey House • Nick Boyce, Fife House • Peggy Millson, U of T • Tarry Steckly, Community • Winston Husbands, ACT

Rationale

• Studies link alcohol and drug consumption with unsafe sexual behaviours among gay/bisexual men • Higher rates of alcohol and drug consumption have been documented amongst gay and bisexual men • Alcohol and drug treatment may reduce risks but few men attend treatment • Motivational interviewing (MI) shows great promise for behavioural change, including sexual and drug and alcohol consumption • MI – client centred, non-judgmental approach focused on assisting individuals to resolve ambivalence toward behaviour change

Project objectives

• Develop a transdisciplinary team including researchers, clinicians, community-based service providers, policy-makers and community members • Develop an intervention model suitable for community-based settings • Build capacity for group interventions, MI, knowledge sharing and collaboration • Complete a pilot study of the intervention.

Research questions

Primary • Does group-based motivational interviewing with a harm reduction focus result in reductions in high HIV-risk sexual behaviours (unprotected anal intercourse)?

Secondary questions/outcomes: • Are reductions in sexual HIV risk behaviours (if any) mediated by overall reductions in substance use OR situational substance use proximal to sexual activity?

• Are there differences between HIV-positive and HIV-negative men in terms of the impact of group based MI on sexual risk reduction?

• Does it make a difference if groups are mixed serostatus vs. similar serostatus?

Research questions

Process/KTE outcomes: • What elements of training, supervision, review and case discussions appear most advantageous in the successful adaptation of motivational interviewing to HIV prevention work?

• Do community workers trained in MI, find this approach to be relevant to their other work?

• What knowledge, skills, references and supports do community workers feel is necessary for successful application of MI in their practice?

Study design

• Longitudinal intervention conducted with 3 groups (mixed serostatus; HIV negative; HIV positive) • Inclusion criteria – Age 18 or older – In past 60 days, had unprotected anal intercourse with a man while drunk or high – English speaking – Self identify as gay or bisexual • Exclusion criteria – Non-substance induced psychotic disorder – Actively suicidal – Partner, lover, boyfriend of another study participant • N=24 – three groups of 8 men

58

# of Contacts

41

Were screened

25

Were eligible

Recruitment

17

Could not be reached

16

Did not meet eligibility criteria

17

HIV-positive

8

HIV-negative

Measures

• • • • • – – – – – – Demographics Sexual orientation and HIV status Mental health – SCID substance dependence, Beck Depression, Penn State Worry Questionnaire, Social adjustment scale, internalized homophobia scale, HIV knowledge Readiness ruler for behavioural change drugs, sexual behaviour in general, unprotected anal intercourse Importance, confidence, realistic Timeline follow-back - unprotected sexual events Gender, HIV status, casual or a regular partner Sexual behaviours, condom use, location - bathhouse Drug use before or during sex with this partner Alcohol consumption before or during sex with this partner

7 wk group based MI using a harm reduction model

• GOAL: – Help gay, bi men who use drugs and/or alcohol lead balanced healthy and fulfilling lives by considering the roles drugs play in their life and how to reduce the risks to themselves, their loved ones and the community.

• Schedule – Baseline research interview (paid) – Individual pre-group meeting with facilitators to define goals and expectations – 7 group sessions lasting 1.5 hours – Exit interview with facilitators – End of intervention research interview (paid) – 3 month follow-up research interview (paid)

Intervention

• Week 1 • Introductions, norms/expectations of the group • What drugs do we use, like and dislike • Week 2: How drugs fit in my life • Benefits, impacts and costs of drugs in our lives & those we love • Harm reduction information will be integrated into conversation in this week and next week • Week 3: How drugs fit in my life • Share information about different substances, dispelling myths, harm reduction strategies

Intervention

• Week 4 – Drugs, sex and sexuality – How drugs fit into our sex lives – Role of drugs, sex and identity in the community – HIV and sexual risk taking and drugs • Week 5 – When this much is too much – Discussion of dependence and drug-related harms – Decisional balance exercise

Intervention

• Week 6 – Setting my goals – Next steps and goal setting – What might get in the way of this?

• Week 7 – My community & closing – How will this work with my friends, my community?

– What can we be doing to help those close to us?

– What can we be doing to help others in the community?

– Say goodbye

Baseline data on subjects recruited to date

• Five individuals withdrew/were deemed ineligible at baseline hence 20 people are included here: • Age: average 44.3 (s.d. 10.9) • 16 were HIV-positive • 18 identified as gay, 1 as bisexual, and 1 as two spirited • 17 reported they were single/never married, 2 as separated, and 1 as divorced

Baseline demographics (continued)

• Highest level of education: 2 some high school, 1 completed high school, 5 some college or university, 2 completed community college, 8 completed university, 2 other • Employment: 1 works full-time, 6 work part-time, 9 not-employed or on disability, 1 self-employed, 3 other (one is a current student) • Income: average $11,234 (s.d. $11,358)

Baseline data (continued)

• Beck Depression Inventory: avg 16.5 (s.d. 9.8) [n=15] • 6 (30%) reported physical abuse as a child • 2 (10%) reported being sexually abused as a child by a female offender and 9 (45%) by a male offender

Lessons learned: Recruitment

• Recruitment of HIV – positive subjects was much easier through existing networks of care providers • HIV – negative subjects were much more likely to be marginally housed, and therefore to have less stable contact numbers making it difficult to follow up with these individuals • Different strategies necessary for HIV – negative men

Successes to date - KTE

• Participation in training indicative of interest and need for MI within the community • Congruency between counseling approaches used by our community partners and motivational interviewing • Interest in extending MI approach to other programming areas within ASOs • Success with MI approach has positively influenced the ways in which education and outreach are viewed by staff

Successes to date : KTE 2

• Training model – Breaking up training over several weeks allows participants to practice integrating the principles from early on in the training – Improved uptake of MI principles and practices • Integration of clinical supervision into the training and especially into the group process has proven quite valuable to facilitators in developing MI facility • Inviting other community agencies to attend free training extended the benefits beyond the focal team to other agencies

Moving forward

• Recruit and conduct group #3 • Review successes and challenges • Develop strategies to overcome challenges of the group format for implementation in the community • Expand community partnerships for a larger intervention study – extend east, west and north • Consider option of also testing a briefer 1-on-1 model