HIV/STD SAFER SEX SKILLS GROUPS
FOR MEN IN METHADONE
MAINTENANCE OR DRUG-FREE
OUTPATIENT TREATMENT
PROGRAMS
• Lead Investigator: Donald Calsyn, Ph.D.
Washington Node
• Co-lead Investigator: Susan Tross, Ph.D.
Long Island Node
Literature Reviews of Studies
Demonstrating the HIV Prevention
Effect of Drug Abuse Treatment
 Metzger, D.S., Navaline, H. & Woody, G.E.
(1998). Drug abuse treatment is AIDS
prevention. Public Health Reports, 113(S1), 97106.
 Sorenson, J.L. & Copeland, A.L. (2000). Drug
abuse treatment as an AIDS prevention strategy:
a review. Drug and Alcohol Dependence, 59,
17-31.
Percent HIV+
Change in Seroprevalence of HIV among
IDUs in and out of Drug Treatment in
Philadelphia 1989-1991
50
45
40
35
30
25
20
15
10
5
0
Baseline
18 Mo. Follow up
33%
11%
15%
In Treatment
(n=152)
Metzger et al. 1993, JAIDS
18%
Out of Treatment
(n=103)
Percent HIV+
Seroprevalence of HIV among IDUs in
and out of Drug Treatment in Uppsala
Sweden 1984
50
45
40
35
30
25
20
15
10
5
0
33%
3%
Community IDUs
Blix & Gronbladh, 1991
In MM Treatment
Prior to 1979 (n=67)
Variables Correlated with the Sexual
Behavior Effect Size in a Meta-Analysis of
HIV Interventions in Drug Treatment
Non-minority samples
Use of separate sex sessions
Use of self control skills training
Peer group discussion
Number of techniques used
Use of didactic lectures
Condom distribution
Prendergast et al, 2001, JCCP
r=0.72
r=0.69
r=0.59
r=0.67
r=0.63
r=0.59
r=0.48
Components of the Schilling et al.
Skills Building Groups for Women
Sessions
1-2. AIDS prevention and transmission, self
identification of HIV risk, group discussion of
barriers
3. Discussion of negative aspects of condoms,
condom familiarity exercises, negotiation
skills
4-5. Assertiveness training, problem solving,
communication skills for safer sex, role
plays of scripted scenarios and
personalized scenarios
Session Outline for
“Time Out! For Men”
Exploration of relationships
Challenging gender role stereotypes
Communications Skills (listening, conflict
resolution, expressing feelings, assertiveness)
Sexual health and sexual functioning
Sexual responsibility in relationships
Making relationships work
Bartholowmew & Simpson, 1996
Findings from “Time Out! For
Men” Study
7
Wait Control
TOFMen
90
80
6
Wait Control
TOFMen
5
60
Rating
percent Correct
70
50
4
40
3
30
20
2
10
1
0
Pre-Test
Post Test
Knowledge Test
Pre-Test
Post Test
Gender Roles
Pre-Test
/
Post Test
Sexual Beliefs
Bartholowew et al, 2000, JSAT
Session Outline for
“HIV/AIDS Update”
HIV information
HIV transmission risk behaviors
Risk reduction behaviors (injection and
sexual)
Personal health protection rights
Assertiveness skills for HIV risk reduction
HIV testing
Bartholomew & Simpson, 1994
Session Outline for
“Project Light”
Group set up and HIV Information
Identifying HIV risk transmission triggers
Controlling triggers – Risk reduction problem
solving, positive self talk
Condom skills, outercourse
Communication skills, assertive talk, creative
negotiation, turning around what they say
Relapse prevention
Findings from “Project Light”
Number of Unprotected Intercourse Acts
30
Frequency
25
*
20
Proj. Light (n=684)
Control (n=657)
*
15
10
5
*p<.001
0
Baseline
3 Month
6 Month
Assessment Period
NIMH Multisite HIV Prevention Trial Group, 1998, Science
Findings from “Project Light”
Percentage
Percentage of Consistent Condom Use or Abstinence
100
90
80
70
60
50
40
30
20
10
0
Proj. Light (n=684)
Control (n=657)
*
*
*p<.001
Baseline
3 Month
6 Month
Assessment Period
NIMH Multisite HIV Prevention Trial Group, 1998, Science
Findings from “Project Light”
Proportion
Proportion of Condom Use for Intercourse Acts
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Proj. Light (n=684)
Control (n=657)
*
*
*p<.001
Baseline
3 Month
6 Month
Assessment Period
NIMH Multisite HIV Prevention Trial Group, 1998, Science
Frequency of Combining Sex and Drugs as
a Function of Treatment Status
Percent of Subjects
60
None
1 to 25%
>25 %
50
40
30
20
10
0
In Tx
Out of Tx
Males
Calsyn et al, 1995, CPDD
In Tx
Out of Tx
Females
Percent of Subjects
Percent Rating Sex as More Pleasurable
under the Influence of Drugs
100
90
80
70
60
50
40
30
20
10
0
Frequency of Combining
Sex & Drugs
Seldom
Often
Vaginal
Intercourse
Fellatio
Males
Calsyn et al, 1995, CPDD
Cunnilingus
Vaginal
Intercourse
Fellatio
Cunnilingus
Females
Percentage of Males and Females Combining
Drug Use with Most Recent Sexual Event
Females
Males
15%
22%
31%
23%
11%
67%
31%
Both Used
Calsyn et al, 1999, CPDD
Partner Only Used
Neither Used
Respondent Only Used
Percent
Increased Sexual Desire as a Function
of Primary Drug of Abuse
100
90
80
70
60
50
40
30
20
10
0
Men
Women
Alcohol
Opiate
Cocaine
Methamphetamine
Primary Drug of Abuse
Rawson et al., 2002, JSAT
Percent
Improved Sexual Performance as a
Function of Primary Drug of Abuse
100
90
80
70
60
50
40
30
20
10
0
Men
Women
Alcohol
Opiate
Cocaine
Methamphetamine
Primary Drug of Abuse
Rawson et al., 2002, JSAT
Percent
Enhanced Sexual Pleasure as a
Function of Primary Drug of Abuse
100
90
80
70
60
50
40
30
20
10
0
Men
Women
Alcohol
Opiate
Cocaine
Methamphetamine
Primary Drug of Abuse
Rawson et al., 2002, JSAT
Percent
Sexual Infidelity as a Function of
Primary Drug of Abuse
100
90
80
70
60
50
40
30
20
10
0
Men
Women
Alcohol
Opiate
Cocaine
Methamphetamine
Primary Drug of Abuse
Rawson et al., 2002, JSAT
Percent
Engaging in Unusual Sex Acts as a
Function of Primary Drug of Abuse
100
90
80
70
60
50
40
30
20
10
0
Men
Women
Alcohol
Opiate
Cocaine
Methamphetamine
Primary Drug of Abuse
Rawson et al., 2002, JSAT
Percent
It Will Be Difficult to Separate
Substance Use from Sexual Behavior
100
90
80
70
60
50
40
30
20
10
0
Men
Women
Alcohol
Opiate
Cocaine
Methamphetamine
Primary Drug of Abuse
Rawson et al., 2002, JSAT
Study Schema
Advertise Study Availability

Consent to Screen for Inclusion/Exclusion & Screening Assessment

Obtain Informed Consent from Eligible Participants

Conduct Baseline Assessment

Randomly Assign to Intervention


Standard HIV Education
Gender Specific Intervention
(one session)
(five sessions)


Conduct Post Intervention Assessment

Conduct Three Month Follow Up Assessment

Conduct Six Month Follow Up Assessment
Inclusion / Exclusion Criteria
Inclusion Criteria:
•
•
•
•
1. Adult males in treatment at a participating CTP
2. Self report engaging in unprotected vaginal or anal
intercourse during the past 6 months.
3. Agreeable to random assignment.
4. Agreeable to completing 2-3 hour assessment battery at
baseline, 2 weeks post intervention, three weeks post
intervention, and six weeks post intervention.
Exclusion Criteria:
• 1. Observable, gross mental status impairment – including
•
severe distractibility, incoherence or retardation
2. Observable psychotic symptoms or severe psychiatric
distress
Primary and Secondary Outcomes
Primary Outcome Variable
The number of unprotected vaginal and anal sex
Secondary Outcome Variables
Attitude towards condoms
Possessing condoms
Intent to use condoms
Percentage of sexual events in which drug use
occurred
Frequency of “outer course”
Gender role beliefs
Number of sexual partners
HIV Education (Control Group)
I. Group Introductions. Goals and Guidelines
5 Min
II. IV. HIV/AIDS Update
15 Min
III. HIV Risky Behaviors, injection practices
10 Min
IV. HIV Risky Behaviors, sexual practices
V. Condom demonstration
10 Min
10 Min
VI. Healthy Options
10 Min
REMAS: Real Men are Safe
1. HIV/AIDS Update: Identifying Risks
2. HIV/AIDS Update: Planning Prevention
3. Sex without drugs. Can it happen? Is it
Pleasurable?
4. Which Planets are Men and Women From?
Exploring and Confronting Gender Stereotypes
5. Beyond the pick up line, communicating about sex
REMAS: Real Men are Safe
Session 1
HIV/AIDS Update: Identifying Risks
I. Group Introductions. Goals and Guidelines
10 Min
II. Getting Started
III. HIV Risky Behaviors Exercise
IV. HIV/AIDS Update
10 Min
15 Min
15 Min
V. HIV Risky Behaviors, injection practices
VI. HIV Risky Behaviors, sexual practices
VII. Condom demonstration
10 Min
10 Min
10 Min
VIII. Revisit Risky Behaviors Exercise
10 Min
REMAS: Real Men are Safe
Session 2
HIV/AIDS Update: Planning Prevention
I. Welcome, redo introductions
5 Min
II. Healthy options
10 Min
III. Barriers to Condom Use
10 Min
IV. Condom Practice
20 Min
V. Identifying Triggers
25 Min
VI. Risk Reduction Problem Solving
20 Min
REMAS: Real Men are Safe
Session 3
Sex without drugs. Can it happen? Is it Pleasurable?
I. Welcome, redo introductions
5 Min
II. Experience with combining sex & drugs 40 Min
Enhancements/Impairments
III. Enhancing sex without drugs
25 Min
IV. Coping with sexual impairment
without drugs
20 Min
REMAS: Real Men are Safe
Session 4
Which Planets are Men and Women
From? Exploring and Confronting
Gender Stereotypes
I. Welcome, redo introductions
5 Min
II. Challenging Stereotypes
30 Min
III. Sexual Myths
20 Min
IV. Unwritten rules
10 Min
V. Responsibility in sexual relationships
25 Min
REMAS: Real Men are Safe
Session 5
Beyond the pick up line, communicating
about sex
I. Welcome, redo introductions
5 Min
II. Communicating about Safe Sex
20 Min
III. Practice TALK
15 Min
IV. Turning Around Partner Objections
20 Min
V. Creative Negotiation
VI. Closing/Wrap-up
20 Min
10 Min
Example of “Creative Negotiation”
Exercise from Project Light
James suspects that his wife may be seeing
someone else on the side. But when he
asked her about it, she denied it. He loves
her and does not want to leave her, but he is
very worried about AIDS and other STDs and
wants to use condoms when they have sex.
She has a bad temper, though, and is very
jealous, so he is afraid to bring up the issue
of sexually transmitted disease directly.
Example of “Creative Negotiation”
Exercise from Project Light
“My health care providers tell me that condoms
may be the safest form of birth control for me.
Other ways (the pill, IUD) can cause problems and
may not be the best for your health. “
“The nurse at the clinic says that I have a
problem with yeast infections. We keep passing it
back and forth to each other. If we use condoms
that won't happen and I can hopefully get rid of the
infection. Sometimes it takes a long time to get rid
of yeast infections, though.”
Group discusses James's options.
Example 2 of “Creative Negotiation”
Exercise from Project Light
“Kareem has wanted to do
Keisha for a long time. Finally, he
gets together with her at a party and
she seems really interested. They
end up at his place and things move
along until he takes out his condom
and starts opening the package.”
Example 2 of “Creative Negotiation”
Exercise from Project Light
Keisha: You don’t need a condom, I’m on the pill
Kareem: “Listen, I once got somebody pregnant that I
didn't mean to, and now I'm just so nervous about
having that happen again that I can't enjoy sex
without knowing I'm secure by wearing a condom.
Nothing's absolutely foolproof, not even the pill.”
Keisha: “But it feels so much better without a
condom.”
Kareem: “Not for me, if I'm distracted worrying about
pregnancy.”
Keisha: “Well, okay, I guess.”
HIV Risk Behaviors at 2 week Posttest for
Women in Skill Building and AIDS
Information Groups
4
Likert Scale
3.5
3
AIDS Info (n=43)
Skills Bldg (n=48)
*
*p< .05
*
*
2.5
2
*
1.5
1
0.5
0
Condom Use
Schilling et al, 1991, Pub Health Reports
Taking
Condoms
Carrying
Condoms
Comfort
Talking about
sex
HIV Risk Behaviors at 15 Month Posttest
for Women in Skill Building and AIDS
Information Groups
4
*p< .05
*
Likert Scale
3.5
3
*
2.5
2
1.5
1
0.5
0
Condom Use
AIDS Info (n=30)
Skills Bldg (n=32)
Taking
Condoms
Carrying
Condoms
Comfort
Talking about
sex
El-Bassel & Schilling 1992, Pub Health Reports
Sexual Enhancements Reported for the Most Recent
Sexual Event in which Drugs Were Used
Percent Identifying the
Sexual Enhancement
70
60
50
40
30
20
10
0
Increased
Desire
Delayed
Orgasm
Increased
Sensation
Social
Inhibition
Sexual
Inhibition
Increased
Potency
Sexual Enhancement
Males
Females
Calsyn et al, 1999, CPDD
Sexual Impairments Reported for the Most
Recent Sexual Event in which Drugs Were Used
Percent Identifying the
Sexual Impairment
70
60
50
40
30
20
10
0
Decreased
Erectile
Desire
Dsyfunction
Delayed
Orgasm
Nonorgasmic
Premature
Ejaculation
Sexual Impairment
Males
Calsyn et al, 1999, CPDD
Females
Decreased
Sensation