Systematic review of cognitive behavioural interventions for HIV risk reduction in substance-using men who have sex with men

Effectiveness of interventions aimed at reducing HIV acquisition and transmission among gay and bisexual men who have sex with men (GBMSM) in high income settings: A systematic review

INTRODUCTION

HIV transmission continues among gay and bisexual men who have sex with men (GBMSM), with those who are younger, or recent migrants, or of minority ethnicity or who are gender diverse remaining at increased risk. We aimed to identify and describe recent studies evaluating the effectiveness of HIV prevention interventions for GBMSM in high income countries.

METHODS

We searched ten electronic databases for randomized controlled trials (RCTs), conducted in high income settings, and published since 2013 to update a previous systematic review (Stromdahl et al, 2015). We predefined four outcome measures of interest: 1) HIV incidence 2) STI incidence 3) condomless anal intercourse (CLAI) (or measure of CLAI) and 4) number of sexual partners. We used the National Institute for Health and Care Excellence (UK) Quality Appraisal of Intervention Studies tool to assess the quality of papers included in the review. As the trials contained a range of effect measures (e.g. odds ratio, risk difference) comparing the arms in the RCTs, we converted them into standardized effect sizes (SES) with 95% confidence intervals (CI).

RESULTS

We identified 39 original papers reporting 37 studies. Five intervention types were identified: one-to-one counselling (15 papers), group interventions (7 papers), online interventions (9 papers), Contingency Management for substance use (2 papers) and Pre-exposure Prophylaxis (PrEP) (6 papers). The quality of the studies was mixed with over a third of studies rated as high quality and 11% rated as poor quality. There was some evidence that one-to-one counselling, group interventions (4-10 participants per group) and online (individual) interventions could be effective for reducing HIV transmission risk behaviours such as condomless anal intercourse. PrEP was the only intervention that was consistently effective at reducing HIV incidence.

CONCLUSIONS

Our systematic review of the recent evidence that we were able to analyse indicates that PrEP is the most effective intervention for reducing HIV acquisition among GBMSM. Targeted and culturally tailored behavioural interventions for sub-populations of GBMSM vulnerable to HIV infection and other STIs should also be considered, particularly for GBMSM who cannot access or decline to use PrEP.

How Alcohol Influences Mechanisms of Sexual Risk Behavior Change: Contributions of Alcohol Challenge Research to the Development of HIV Prevention Interventions

This paper examines the contributions of laboratory-based alcohol challenge research (ACR) to the development of HIV prevention interventions. Following a brief overview of HIV prevention interventions and related health behavior change models, we discuss how alcohol may influence mechanisms of behavior change. The paper highlights the value of ACR for: (1) elucidating mechanisms of action through which alcohol affects sexual risk behavior, (2) testing how alcohol may influence mechanisms thought to underlie HIV prevention interventions, (3) clarifying moderators of the causal influences of alcohol, (4) identifying novel intervention targets, and (5) developing strategies to reduce sexual risk among those who consume alcohol. We conclude with a discussion of the importance of using experimental research to identify mechanisms of behavior change that are specific to populations at high risk for HIV and outline some key implications for developing HIV prevention interventions that integrate the role of alcohol.

Alcohol interventions for LGBTQ+ adults: A systematic review

INTRODUCTION

Gender and sexual minority populations are more likely to drink excessively compared to heterosexual and cisgender people. Existing reviews of alcohol interventions focus on specific subgroups within the lesbian, gay, bisexual, trans*, queer, questioning or otherwise gender or sexuality diverse (LGBTQ+) population and neither identify their theoretical basis nor examine how interventions are tailored to meet the needs of specific subgroups.

METHODS

This systematic review includes published studies reporting the effectiveness of interventions to reduce alcohol use in LGBTQ+ people. The review followed PRISMA guidelines. Quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool.

RESULTS

The review includes 25 studies, with the earliest published in 2005. The majority (n = 20) focused on men who have sex with men; only two included sexual minority women and three included trans* people. Most studies were conducted in the USA (n = 21) and used a randomised design (n = 15). Five studies were assessed to be of strong quality, seven moderate and 13 weak. Interventions were mainly delivered face-to-face (n = 21). The most common approaches used to inform interventions were Motivational Interviewing (n = 8) and Cognitive Behavioural Therapy (n = 8). Nineteen studies reported a significant reduction in alcohol consumption.

DISCUSSION AND CONCLUSIONS

This review suggests that for interventions to be effective in reducing alcohol consumption in LGBTQ+ people, they need to be informed by theory and adapted for the target population. Alcohol interventions that focus on sexual minority women, trans* people and people with other gender identities are needed. The findings have implications for professionals who need to identify when gender and/or sexuality are peripheral or central to alcohol use.

HIV Prevention Research on Men Who Have Sex With Men: A Scoping Review of Systematic Reviews, 1988-2017

In the United States, men who have sex with men (MSM) are disproportionately affected by HIV. To identify research gaps and inform HIV prevention for MSM, we conducted a scoping review of systematic reviews using CDC's Prevention Research Synthesis database. Eligibility criteria comprised English-language systematic reviews focused on HIV prevention for MSM, published during 1988-2017, and included at least one U.S. primary study. We coded data type, subpopulations, topics, and key findings. To assess study quality, we used the Assessment of Multiple Systematic Reviews (AMSTAR). Among 129 relevant systematic reviews, study quality was high or moderate for 63%. Most common topics were sexual behavior and disease vulnerability. The most frequently mentioned MSM subgroups were HIV-positive, Black or African American, and young. Research gaps include Hispanic/Latino MSM, pre-exposure prophylaxis (PrEP), treatment as prevention, social determinants of health, health disparities, syndemics, and protective factors for sexual health.

An examination of grit in black men who have sex with men and associations with health and social outcomes

AIMS

This study sought to examine the prevalence and correlates of grit in a sample of Black men who have sex with men (BMSM) in Baltimore, Maryland.

METHODS

A trained research assistant administered the Short-Grit and Center for Epidemiological Studies Depression (CES-D) scales and surveyed participants of a community-based behavioral health intervention for demographic, health, and sexual behaviors.

RESULTS

Of 239 participants, two-thirds scored in the high grit category. A greater proportion of men with high grit demonstrated higher educational attainment, were employed in the prior 6 months, reported very good/excellent health, were human immunodeficiency virus-positive, scored < 16 on the CES-D, and had more friends who were gay. After controlling for other variables, high grit was associated with higher odds of having more friends who are gay and lower odds of alcohol use, unemployment, and a high CES-D score.

CONCLUSIONS

These findings demonstrate that grit could be an important mechanism upon which to focus health and behavioral interventions for BMSM.

The development of an innovative, theory-driven, psychoeducational HIV/STI prevention intervention for heterosexually active black adolescents with mental illnesses

Sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), continue to disproportionately affect Black adolescents. Those experiencing the psychological sequelae of mental illnesses are at increased risk. Here, we outline the development of an HIV/STI prevention intervention for heterosexually-active Black adolescents with mental illnesses. This research was guided by a psychosocial expansion of the Theory of Planned Behavior, nested within a broader social determinants of health framework. A youth community advisory board provided study oversight. Heterosexually-active Black adolescents aged 14 to 17 were recruited from community-based outpatient mental health providers for focus groups, surveys and two "dress rehearsals" of the intervention protocol (N = 68). The qualitative and quantitative findings indicated that knowledge, attitudes and skills related to consistent condom use, reduced number of sexual partners, routine HIV/STI testing, abstinence and emotion regulation were important areas to target. These elicitation data provided insight on the context of HIV/STI risk for the study population, and were used to develop the intervention content. "Project GOLD: We are Kings and Queens" was designed to be delivered over two days (three hours per day), with eight, 45-minute modules. The activities address behaviors, as well as cognitive, emotional, psychological and social processes associated with HIV/STI risk. Alongside evidence-based HIV/STI prevention strategies (e.g., sexual partner communication skills), the intervention activities are rooted in principles of Cognitive Behavioral Therapy. Dress rehearsal participants were in favor of the intervention and provided feedback on activity length, gender and cultural relevance, and strategies to sustain attention; this information was used to finalize the curriculum. In partnership with the community, we developed a theoretically-driven, gender and culturally relevant, developmentally and psychologically appropriate HIV/STI prevention program. Our ultimate goal is to standardize sexual health assessment and intervention in outpatient mental health treatment settings to meet sexual health needs in this underserved population.

Interventions to address substance use and sexual risk among gay, bisexual and other men who have sex with men who use methamphetamine: A systematic review

BACKGROUND

Methamphetamine use is common among some populations of gay, bisexual and other men who have sex with men (gbMSM). This study reviewed the status of research on the efficacy of interventions that address harms among gbMSM who use methamphetamine.

METHODS

We searched MEDLINE, PsycINFO, CINAHL, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar to identify publications from inception to October 23, 2017, that assessed an intervention addressing methamphetamine use among gbMSM.

RESULTS

Of 1896 potential studies and 935 unique articles screened for inclusion, 28 eligible studies assessed 26 different interventions in the following categories: pharmacological (n = 5); psychosocial (n = 20); harm reduction (n = 1). Given that outcome variables were measured in highly variable ways, we were unable to conduct a meta-analysis of intervention effects. However, 22 studies reported a statistically significant effect on one or more methamphetamine-related outcomes. Among 21 studies that included measures of sexual health-related outcomes, 18 reported a significant effect on one or more sexual health-related outcomes, and 15 of those reported a concurrent effect on both drug- and sexual health-related outcomes.

CONCLUSIONS

This is the first review to provide compelling evidence that integrating interventions to address both drug- and sexual-related harms for gbMSM who use methamphetamine can be efficacious. Future research should focus on identifying differential effects of various intervention approaches by social positioning, as well as prioritize future evaluations of integrated harm reduction interventions (e.g., the distribution of harm reduction kits within sexual health care settings).

Temporal Relationship of Sex Risk Behaviors and Substance Use Severity Among Men in Substance Use Treatment

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, men in methadone maintenance and outpatient drug-free treatment (N = 359) completed assessments at baseline and six months after. We assessed changes in sex risk and substance use severity, 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. 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.

The clinical effectiveness of individual behaviour change interventions to reduce risky sexual behaviour after a negative human immunodeficiency virus test in men who have sex with men: systematic and realist reviews and intervention development

BACKGROUND

Men who have sex with men (MSM) experience significant inequalities in health and well-being. They are the group in the UK at the highest risk of acquiring a human immunodeficiency virus (HIV) infection. Guidance relating to both HIV infection prevention, in general, and individual-level behaviour change interventions, in particular, is very limited.

OBJECTIVES

To conduct an evidence synthesis of the clinical effectiveness of behaviour change interventions to reduce risky sexual behaviour among MSM after a negative HIV infection test. To identify effective components within interventions in reducing HIV risk-related behaviours and develop a candidate intervention. To host expert events addressing the implementation and optimisation of a candidate intervention.

DATA SOURCES

All major electronic databases (British Education Index, BioMed Central, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Educational Resource Index and Abstracts, Health and Medical Complete, MEDLINE, PsycARTICLES, PsycINFO, PubMed and Social Science Citation Index) were searched between January 2000 and December 2014.

REVIEW METHODS

A systematic review of the clinical effectiveness of individual behaviour change interventions was conducted. Interventions were examined using the behaviour change technique (BCT) taxonomy, theory coding assessment, mode of delivery and proximity to HIV infection testing. Data were summarised in narrative review and, when appropriate, meta-analysis was carried out. Supplemental analyses for the development of the candidate intervention focused on post hoc realist review method, the assessment of the sequential delivery and content of intervention components, and the social and historical context of primary studies. Expert panels reviewed the candidate intervention for issues of implementation and optimisation.

RESULTS

Overall, trials included in this review (n = 10) demonstrated that individual-level behaviour change interventions are effective in reducing key HIV infection risk-related behaviours. However, there was considerable clinical and methodological heterogeneity among the trials. Exploratory meta-analysis showed a statistically significant reduction in behaviours associated with high risk of HIV transmission (risk ratio 0.75, 95% confidence interval 0.62 to 0.91). Additional stratified analyses suggested that effectiveness may be enhanced through face-to-face contact immediately after testing, and that theory-based content and BCTs drawn from 'goals and planning' and 'identity' groups are important. All evidence collated in the review was synthesised to develop a candidate intervention. Experts highlighted overall acceptability of the intervention and outlined key ways that the candidate intervention could be optimised to enhance UK implementation.

LIMITATIONS

There was a limited number of primary studies. All were from outside the UK and were subject to considerable clinical, methodological and statistical heterogeneity. The findings of the meta-analysis must therefore be treated with caution. The lack of detailed intervention manuals limited the assessment of intervention content, delivery and fidelity.

CONCLUSIONS

Evidence regarding the effectiveness of behaviour change interventions suggests that they are effective in changing behaviour associated with HIV transmission. Exploratory stratified meta-analyses suggested that interventions should be delivered face to face and immediately after testing. There are uncertainties around the generalisability of these findings to the UK setting. However, UK experts found the intervention acceptable and provided ways of optimising the candidate intervention.

FUTURE WORK

There is a need for well-designed, UK-based trials of individual behaviour change interventions that clearly articulate intervention content and demonstrate intervention fidelity.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42014009500.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Risk Factors for Hepatitis C Virus Reinfection After Sustained Virologic Response in Patients Coinfected With HIV

Background.

Highly effective hepatitis C virus (HCV) therapies have spurred a scale-up of treatment to populations at greater risk of reinfection after sustained virologic response (SVR). Reinfection may be higher in HIV–HCV coinfection, but prior studies have considered small selected populations. We assessed risk factors for reinfection after SVR in a representative cohort of Canadian coinfected patients in clinical care.

Methods.

All patients achieving SVR after HCV treatment were followed with HCV RNA measurements every 6 months in a prospective cohort study. We used Bayesian Cox regression to estimate reinfection rates according to patient reported injection drug use (IDU) and sexual activity among men who have sex with men (MSM).

Results.

Of 497 patients treated for HCV, 257 achieved SVR and had at least 1 subsequent RNA measurement. During 589 person-years of follow-up (PYFU) after SVR, 18 (7%) became HCV RNA positive. The adjusted reinfection rate (per 1000 PYFU) in the first year after SVR was highest in those who reported high-frequency IDU (58; 95% credible interval [CrI], 18–134) followed by MSM reporting high-risk sexual activity (26; 95% CrI, 6–66) and low-frequency IDU (22; 95% CrI, 4–68). The rate in low-risk MSM (16; 95% CrI, 4–38) was similar to that in reference patients (10; 95% CrI, 4–20). Reinfection rates did not diminish with time.

Conclusions.

HCV reinfection rates varied according to risk. Measures are needed to reduce risk behaviors and increase monitoring in high-risk IDU and MSM if HCV elimination targets are to be realized.

Illicit drug use and its association with sexual risk behaviour among MSM: more questions than answers?

PURPOSE OF REVIEW

Illicit drug use before or during sex - known as sexualized drug use (colloquially 'chemsex' or 'party and play') - has evolved as novel psychoactive substances have entered the market in many parts of the world. Here, we review key conceptual issues in associations between illicit drug use and sexual risk-behaviour in MSM.

RECENT FINDINGS

Although many studies have confirmed that MSM use drugs with greater prevalence than the general population, evidence is of variable quality and a sampling frame is difficult to establish. Moreover, psychosocial hypotheses linking drug use and sexual risk, including cognitive escape and sensation seeking, are unsatisfactory and generally ignore strategic use of drugs for sexual aims. Person-level associations between drug use history and both sexual risk behaviour and HIV infection tend to be consistent around the world, but evidence comparing encounters within subjects is generally unclear and out of date.

SUMMARY

There is a need for interventions for harm reduction targeted at MSM that account specifically for the social and cultural contexts of sexualized drug use. Expanded attention to surveillance of emerging drug use trends can help clinicians in sexual health and infectious diseases best anticipate the needs of their service users.

Findings from within-subjects comparisons of drug use and sexual risk behaviour in men who have sex with men in England

Epidemiological evidence for the encounter-level association between sexualised drug use and unprotected anal intercourse in men who have sex with men is unclear and has not examined men who have sex with men in England. To estimate this association, we compared dyadic sexual encounters within respondents. We used encounter-level data from a longitudinal online survey of men who have sex with men living in England and multilevel models to test univariate and multivariate associations between any respondent or partner drug use, specific respondent drug use, additional situational characteristics and unprotected anal intercourse. Based on 6742 encounters from 2142 men who have sex with men, respondent drug use and respondent use of certain specific drugs were associated with increased unprotected anal intercourse odds. In univariate models, partner drug use was associated with increased unprotected anal intercourse odds, but in multivariate models, only non-specific knowledge of partner drug use was associated with the same. Encounters with non-regular-and-steady partners or that were not HIV-seroconcordant were associated with decreased unprotected anal intercourse odds. This is the first within-subjects comparison of drug use and unprotected anal intercourse conducted on a sample from England, and the largest of its kind. Findings are consistent with other studies, though associations between drug use and unprotected anal intercourse are shaped by social contexts that may change over time.