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The NIDA National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) is devoted to the development of effective interventions for people who use substances across a variety of populations. When positive outcomes of a particular intervention do not generalize to other groups, adaptation may improve effectiveness for a different target group. However, currently limited information is available for involving community participation in cultural adaptation.
The current paper illustrates the evolution of our methodology for community engaged cultural adaptation by describing a series of sexual health and substance use interventions. We highlight the transition from minimal community involvement (the Delphi process), to moderate community involvement (theater testing), to full community engagement in cultural adaptation. Ultimately, the results of these three projects led to the development of Community Collaborative Cultural Adaptation, a novel and concrete approach to cultural adaptation. This approach emphasizes the advantage of establishing academic/community partnerships for cultural adaptation to increase the effectiveness and sustainability of interventions.
Related protocols: CTN-0018
Sex risk behaviors and substance use are intertwined. Many men continue to engage in high-risk sexual behaviors even when enrolled in substance use disorder (SUD) treatment. We hypothesized that changes in sex risk behaviors would coincide with changes in drug/alcohol use severity among men in SUD treatment. During an HIV risk-reduction trial, CTN-0018, men in methadone maintenance and outpatient drug-free treatment (N=359) completed assessments at baseline and six months after. Changes in sex risk and substance use severity were assessed using the Addiction Severity Index-Lite (ASI-Lite), controlling for treatment condition.
In multinomial logistic regressions, decreased alcohol severity was significantly associated with decreases in reported sex partners, and increased alcohol severity was significantly associated with increases in reported sex partners. Increasing drug use severity was significantly associated with maintaining and initiating sex with a high-risk partner, while decreasing alcohol use severity was significantly associated with discontinuing sex under the influence. However, changes in drug/alcohol use severity were not associated with changes in unprotected sex.
Conclusions: Substance use reductions may decrease HIV risk behaviors among male substance users. Our findings highlight the importance of integrating interventions in SUD treatment settings that address the intersection of sex risk behaviors and substance use.
Related protocols: CTN-0018
Receptive anal sex has high human immunodeficiency virus (HIV) transmission risk, and heterosexual substance-abusing individuals report higher anal sex rates compared to their counterparts in the general population. This secondary analysis of two NIDA Clinical Trials Network studies (CTN-0018 and CTN-0019) evaluated the effectiveness of two gender-specific, evidence-based HIV prevention interventions (Real Men are Safe, or REMAS, for men; Safer Sex Skill Building, or SSSB, for women) against an HIV education (HIV-Ed) control condition on decreasing unprotected heterosexual anal sex (HAS) among substance abuse treatment-seeking men (n=171) and women (n=105). Two variables, engagement in any HAS and engagement in unprotected HAS, were assessed at baseline and three months post-intervention.
Compared to the control group, women in the gender-specific intervention did not differ on rates of any HAS at follow-up but significantly decreased their rates of unprotected HAS. Men in both the gender-specific and the control interventions reported less HAS and unprotected HAS at three-month follow-up compared to baseline, with no treatment condition effect.
Conclusions: Women and men showed different patterns when it came to unprotected HAS. For men, rates of unprotected HAS decreased overall in the sample, and patterns suggest the reduction may, at least partly, reflect their decreased rates of engaging in any HAS. On the other hand, SSSB women did show a decrease in unprotected HAS compared to controls despite no significant difference in overall HAS rates. For them, the results suggest the SSSB intervention did produce intentional action toward risk reduction. The mechanism of action for SSSB compared to REMAS in decreasing unprotected HAS is unclear. More attention to HAS in HIV-prevention interventions for heterosexual men and women in substance abuse treatment is warranted.
Related protocols: CTN-0018, CTN-0019
HIV transmission often occurs through heterosexual high-risk sex. Even in the era of HIV combination prevention, promoting condom use and understanding barriers to consistent condom use remain priorities, especially among substance-dependent individuals.
This secondary analysis used data from CTN-0018 and CTN-0019, two NIDA Clinical Trials Network studies that compared a five-session gender-specific risk reduction group (Real Men Are Safe for men, Safer Sex Skills Building for women) to a one-session HIV Education Group for men and women (N=729) in outpatient drug treatment. Condom barriers (Motivation, Partner-Related, Access/Availability, Sexual Experience) were assessed at baseline and 6-month follow-up.
Intervention condition was not associated with condom barriers across any of the four domains; however, individuals who attended at least three of the five SSSB/REMAS sessions or the single session of HIV Education were more likely to report fewer motivation and partner-related barriers. Among women, reductions in motivation and sexual experience barriers were associated with less sexual risk with primary partners. For both men and women, reductions in partner-related barriers were associated with fewer unprotected vaginal/anal sex acts with primary partners.
Conclusions: Condom barriers are important to gender-specific HIV prevention; given limited resources, brief interventions maximizing active components are needed.
Related protocols: CTN-0018, CTN-0019
Although HIV prevention during substance abuse treatment is ideal, existing HIV risk-reduction interventions are less effective among Black and other ethnic minority substance abusers. The Sexual Health Model (SHM) and Person, Extended Family and Neighborhood-3 model (PEN-3) both highlight the importance of increasing our understanding of the relationship of sociocultural factors to sexual decision-making as a step towards developing more HIV prevention interventions for ethnic minorities. However, few studies examine sociocultural factors in the sexual decision-making process of Black substance abusing men. This secondary analysis of data collected in an evaluation of Real Men Are Safe (REMAS), an HIV prevention intervention, in the NIDA Clinical Trials Network (CTN) addressed this gap by examining the relation of two specific sociocultural factors (i.e., masculinity and perceived barriers to condom use) to the self-reported sexual behaviors of Black substance abusing men with their main and casual female partners.
Analyses of the baseline data of 126 Black men entering substance abuse treatment revealed that the endorsement of both personal and social masculinity predicted more unprotected sexual occasions (USO) with casual partners. The perception that condoms decreased sexual pleasure also predicted higher USO rates with casual partners. However, fewer partner barriers was not associated with USO among casual partners as expected. Neither the endorsement of social or personal masculinity or perceived condom barriers predicted USO with main partners.
Conclusions: These findings suggest that interventions that depict condom use as both pleasurable and congruent with Black male perceptions of masculinity may be more effective with Black substance abusing men than interventions focusing solely on health beliefs or education. Future research should continue to investigate the influence of other sociocultural factors, especially those that influence the sexual decision-making process, on sexual risk behaviors among Black men, as well as other groups.
Related protocols: CTN-0018
This CTN ancillary investigation aimed to examine predictors and moderators of response to two HIV sexual risk interventions of different content and duration for individuals in substance abuse treatment programs. Participants were recruited from community drug treatment programs participating in the National Drug Abuse Treatment Clinical Trials Network (CTN). Data were pooled from two parallel randomized controlled CTN studies, CTN-0018 and CTN-0019 (“Reducing HIV/STD Risk Behaviors: A Research Study for Men/Women in Drug Abuse Treatment”), each examining the impact of a multi-session HIV education intervention, on the degree of reduction in unprotected sex from baseline to 3- and 6-month follow-ups. The findings were analyzed using a zero-inflated negative binomial (ZINB) model.
Severity of drug use, gender, and age were significant main effect predictors of number of unprotected sexual occasions (USOs) at follow-up in the non-zero portion of the ZINB model (men, younger participants, and those with greater severity of drug/alcohol abuse have more USOs). Monogamous relationship status and race/ethnicity were significant predictors of having at least one USO vs. none (monogamous individuals and African Americans were more likely to have at least one USO). Significant moderators of intervention effectiveness included recent sex under the influence of drugs/alcohol, duration of abuse of the primary drug, and Hispanic ethnicity.
Conclusions: These predictor findings and moderator findings point to ways in which patients may be selected for the different HIV sexual risk reduction interventions and suggest potential avenues for further development of the interventions for increasing their effectiveness within certain subgroups, with particular attention to cultural sensitivity.
Related protocols: CTN-0018, CTN-0019
A fidelity measure was developed for use with Real Men Are Safe-Culturally Adapted (REMAS-CA), an HIV prevention intervention for ethnically diverse men in substance abuse treatment developed as an outgrowth of National Drug Abuse Treatment Clinical Trials Network protocol CTN-0018 (Reducing HIV/STD Risk Behaviors: A Research Study for Men in Drug Abuse Treatment). The aims of this ancillary investigation of data from that project were to: 1) assess the reliability of the Fidelity Rating and Skill Evaluation (FRASE); 2) measure improvement in therapist competence and adherence over time while delivering REMAS-CA; and 3) identify which modules of REMAS-CA were most difficult to deliver.
Conclusions: Results showed that the FRASE was a reliable instrument for measuring the fidelity of REMAS-CA delivery, and therapists achieved adequate adherence and competence after training, demonstrating significant improvement over time. Sessions 4 and 5 of REMAS-CA were found to contain the most challenging modules for therapists to deliver. These findings offer some guidelines for increasing counselor competence in implementing REMAS-CA for research or clinical practice. Specifically, more effort should be spent on training the counselors to implement the emotionally charged discussion and the specific skill building present in Sessions 4 and 5.
Related protocols: CTN-0018
The changing ethnic composition of the nation and increasing requirements to use evidence-based treatments (EBTs) challenge mental health professionals to adapt treatments and interventions to be appropriate for their clients. This article applies the available information on cultural adaptation to substance abuse. The most common approaches for adapting substance use interventions include some combination of either community involvement in the adaptation, existing research and literature, and/or consultation from experts to adapt EBTs. As an example of the process used to develop a culturally-adapted intervention, research stemming from National Drug Abuse Treatment Clinical Trials Network protocol CTN-0018 (Reducing HIV/STD Risk Behaviors: A Research Study for Men in Drug Abuse Treatment) is described.
This project found that the Real Men Are Safe (REMAS) protocol was less effective for black male substance users than for whites, leading the research team to develop a culturally adapted version of the intervention. After addressing the sociocultural factors associated with HIV risk behaviors among ethnic minority males abusing substances, the resulting REMAS-CA intervention (Real Men Are Safe – Culturally Adapted) was found to be more effective than the original in reducing HIV risk behaviors in black and Hispanic men. The challenges facing the development of culturally adapted interventions include the need for additional research to determine which specific EBTs warrant adaptation, the responsibility of maintaining the balance between fidelity and adaptation, and the challenge of intragroup diversity.
Related protocols: CTN-0018
Social workers are often on the front lines of the HIV/AIDS epidemic delivering prevention education and interventions, offering or linking individuals to HIV testing, and working to improve treatment access, retention, and adherence, especially among vulnerable populations. Individuals with substance use disorders face additional challenges to reducing sexual and drug risk behaviors, as well as barriers to testing, treatment, and antiretroviral therapy adherence.
This article presents current data on HIV transmission and research evidence on prevention and interventions with substance abusers, and highlights how individual social workers can take advantage of this knowledge in practice and through adoption and implementation with organizations. Research from the National Drug Abuse Treatment Clinical Trials Network (CTN) about rapid HIV testing and gender-specific HIV risk reduction interventions is described.
Related protocols: CTN-0018, CTN-0019, CTN-0032
The National Drug Abuse Treatment Clinical Trials Network (CTN) recently completed a randomized clinical trial evaluating the utility of Real Men Are Safe (REMAS), an HIV prevention intervention for men in substance abuse treatment (protocol CTN-0018). Analysis of the data with a focus on racial/ethnicity-related differences found a differential effect for white versus minority men. This study aimed to determine the acceptability, participants’ receptivity, and effectiveness of a culturally adapted version of Real Men Are Safe (REMAS-CA). In 2010 and 2011, the authors compared participants who attended at least 1 (of 5) REMAS-CA session (n=66) with participants in the original REMAS study (n=136). Participants completed an assessment battery at baseline and at 3-month follow-up with measures of substance abuse, HIV risk behaviors, perceived condom barriers, and demographics. Post-intervention focus groups were conducted at each clinic. Results found that minority REMAS-CA participants were more likely to have attended 3 or more sessions (87%), meeting the study definition of “intervention completion,” than were minority participants in the REMAS study (75.1%; odds ratio: 2.1). For REMAS-CA participants with casual partners (n=25), the number of unprotected sexual occasions in the past 90 days declined (6.2 vs. 1.6). Among minority men in the REMAS study (n=36), the number of unprotected sexual occasions with casual partners changed little (9.4 vs. 8.4).
Conclusions: REMAS-CA was effective across ethnic groups and appears to be more appealing to minorities than the original REMAS intervention. The finding that REMAS-CA was appealing across ethnic groups is especially important because many HIV risk reduction programs serve a diverse clientele and lack the resources to target an intervention solely to one ethnic group.
For substance abuse treatment seekers engaging in high risk sexual behavior, their inconsistent condom use may be related to their condom use attitudes and skills. This study compared treatment-seeking male and female substance abusers in their reported barriers to condom use and condom use skills. Men and women (N = 1,105) enrolled in two multi-site HIV risk reduction studies in the National Drug Abuse Treatment Clinical Trials Network (CTN-0018 and CTN-0019) were administered the Condom Barriers Scale, Condom Use Skills, and an audio computer-assisted structured interview assessing sexual risk behavior. Men endorsed more barriers to condom use, especially on the Effects on Sexual Experience factor. For both men and women, stronger endorsement of barriers to condom use was associated with less use of condoms. However, the difference between condom users and non-users in endorsement of condom barriers in general is greater for men than women, especially for those who report having casual partners.
Conclusions: Results provide additional information about the treatment and prevention needs of treatment-seeking men and women. Understanding differences between men and women in their beliefs, knowledge, and skills related to condom use will allow clinicians to better tailor risk behavior interventions. These results also emphasize that it is important for clinicians to remember that both men and women engage in risky sexual behavior despite being actively involved in substance abuse treatment.
Related protocols: CTN-0018, CTN-0019
Heterosexual anal intercourse (HAI) is an understudied risk behavior among women and men in substance abuse treatment. In this ancillary investigation of data from two National Drug Abuse Treatment Clinical Trials Network (CTN) studies that evaluating gender-specific interventions for reducing HIV/STD risk behaviors for men/women in substance abuse treatment (protocols CTN-0018 and -0019), rates of HAI for women (n=441) and men (n=539) were identified for any, main, and casual partners. More men (32.8%) than women (27.1%) reported engaging in HAI in the previous 90 days. These rates are higher than those reported for both men (6-15,9%) and women (3.5-13%) ages 25-59 in the National Survey of Sexual Health and Behavior. Men were significantly more likely to report HAI with their casual partners (34.1%) than women (16.7%). In a logistic regression model generated to identify associations between HAI and variables previously shown to be related to high risk sexual behavior, being younger, bisexual, and white were significantly associated with HAI. For men, having more sex partners was also a significant correlate.
Conclusions: These data show that more substance abuse treatment-seeking women and men participate in HAI than in the general population and that condom use is low for both genders. Given that heterosexual transmission is a primary means of contracting HIV and the seroconversion risk is greatest for receptive AI, it is vital that any HIV prevention program include material on HAI.
Related protocols: CTN-0018, CTN-0019
Substance abusers are at risk for HIV and other STIs. Heterosexual anal intercourse (HAI) is riskier than vaginal intercourse, and more risky for women than for men. Previous analyses of data from protocols CTN-0018 and CTN-0019 (Reducing HIV/STD Risk Behaviors: A Research Study for Men (0018) and Women (0019) in Drug Abuse Treatment) found that more women and men in substance abuse treatment engaged in HAI than in general population samples. Additionally, more men engaged in HAI than women, and men were more likely to engage in HAI with their casual sex partners than women. Condom use for HAI was infrequent, and younger age, bisexual behavior, being white, and having more sex partners (men) were associated with engaging in HAI.
This study aimed to evaluate the effectiveness of the five session CTN gender-specific HIV prevention interventions, “Real Men Are Safe (REMAS)” (CTN-0018) and “Safer Sex Skill Building (SSSB)” for women (CTN-0019), vs. single session information only control, on decreasing heterosexual anal intercourse (HAI) and increasing condom use for HAI. Men and women enrolled in the two protocols who reported heterosexual activity at baseline, attended SSSB/REMAS or the control condition, and completed the 3-month follow-up were included in the analysis. Results of the study found that the percent of men, but not women, engaging in HAI decreased from baseline to 3 month follow-up, with the decrease for men similar for both REMAS and control condition participants. Although condom use for HAI remained infrequent, the percentage of both women and men reporting any use of condoms for HAI increased between baseline and follow-up. Women attending SSSB were more likely to change from no condom use to some condom use than women attending the control intervention. A similar non-significant trend was noticed for men attending REMAS as well.
Related protocols: CTN-0018, CTN-0019
The presentation reports on a study designed to revise the CDC recognized, evidence-based HIV prevention intervention, “Real Men Are Safe” (REMAS) to be more culturally relevant to African American and Hispanic men, and then conduct a pilot feasibility trial of the revised REMAS (REMAS-CA) in four CTN community treatment providers that have a high percentage of minority clients. Comparisons between the original REMAS manual and four culturally tailored interventions (Nia, d-up, Many Men Many Voice, and Cuidate) were made, focusing in particular on language/expressions of the target group; activities that enhance ethnic identity, consistency with the norms, knowledge, and cultural values of the target group; and understanding of the social context and living situations of the target group. Resultant changes to the original intervention are described, along with data and feedback from focus groups following pilot testing of the REMAS-CA.
Related protocols: CTN-0018
The National Drug Abuse Treatment Clinical Trials Network (CTN) recently completed a randomized clinical trial (CTN-0018) evaluating an HIV prevention intervention targeting men in substance abuse treatment called “Real Men Are Safe (REMAS).” REMAS was found to be effective at reducing the number of unprotected sexual occasions for men in substance abuse treatment compared to an HIV education control intervention. This CTN ancillary study used a modified Delphi process to compare modules from REMAS to similar-content modules from other CDC-approved, culturally tailored HIV prevention interventions. Utilizing ratings and recommendations obtained from an independent expert panel, REMAS was subsequently revised to be more culturally adapted for an ethnically diverse group of men. Ratings suggested REMAS was culturally fair, but that in certain areas the culturally tailored interventions were more in tune with African Americans and Hispanic men. Revisions to REMAS included an added focus on how culture, social norms, and upbringing affect a man’s sexual behavior and relationships.
Related protocols: CTN-0018