One of the challenges to developing effective behavioral interventions for marginalized and resource-limited populations, such as injection drug users, is the ability to sustain the effect of the skills training beyond 6 months20
. Decay of intervention effects may occur because of lack of contact with program and interruptions to practice and use of skills. Results from an 18 month follow-up period indicate that the STEP intro Action intervention was efficacious for Index participants in 1) sustaining reductions in injection risk and sharing a cooker to split drugs, 2) reducing sex risk behaviors and 3) increasing communication about HIV prevention.
A novel aspect of the current study is that Health Educators were trained to focus on HIV risk reduction conversations with individuals in their personal risk network, as opposed to general peer-based outreach. The intervention was designed to integrate behavior change into daily activities and conversations within natural social settings as a method to enhance sustainability of the intervention. Furthermore, salience and credibility of the risk reduction message is increased because it is delivered by a similar other21
within the personal network.
Drawing from Social Identity theory22
, this intervention sought to establish the role of Health Educator in which norms for personal risk reduction was emphasized. We found that intervention condition Indexes were more likely to have HIV prevention conversations as compared to control. The repeated conversations about HIV prevention may serve to reinforce the identity of peer Health Educator which then influenced behavior to be consistent with their conversations16
. Intervention condition was significantly more likely to reduce risks associated with sharing a cooker to split drugs and to talk with their risk network about the needle-less syringe as an option for splitting liquid drugs more safely. This result has implications for addressing hepatitis C transmission, especially to individuals who are initiating drug use, which has been identified as a critical time for hepatitis C infection23
. Future interventions for IDUs should increase knowledge about risks associated with splitting drugs in a liquid form and alternative methods for safer splitting.
We report evidence of intervention effect on sex risk of female RNM. Nearly one-third of the RNMs recruited and enrolled were named by the Index as a sex partner. Drug users are often enmeshed in dense social networks that contain a diversity of ties ranging from kin to drug-using associates and multiplex risk relationships such as having a network who is both an injection and sex partner. The dyad session was developed to enable the Health Educator to continue to practice their skills with a specific RNM and to facilitate conversations that focus on risk reduction goals of the pair. As conversations about risk behavior can be uncomfortable, providing a safe setting where these conversations are perceived as normative can alleviate reluctance to participate. As few interventions have shown a reduction in sexual risk behaviors among injectors19
this finding is promising and suggests feasibility in recruiting sex partners of injectors for inclusion in intervention activities.
We observed a strong effect of the control condition on conversations about overdose which suggests that there are additional health topics that are salient for injection drug users. It is important to remember the broader context of injection drug users lives22
, to acknowledge that HIV prevention may not be the priority for all IDUs, and to examine drug-related risk behaviors beyond HIV risks22,23
. Developing programs that are flexible to a range of drug users will increase the potential audience for any intervention, thus increasing exposure to prevention information. The control condition also decreased sex and injection risk behaviors possibly due to HIV testing and pre and post-test counseling provided in accordance with the CDC guidelines which have been found to be effective in reducing risk behaviors.
Limitations should be noted. The sample for this study were older and primarily heroin injectors, which limits the generalizability of the findings. Additional trials are needed to determine whether the peer outreach training would be effective in reducing risk for younger injectors or crack and methamphetamine smokers, who do not inject. Despite having research staff contact and remind Index participants about network recruitment, only 50% of those behaviorally eligible participants were successful in recruiting a network to enroll into the study. Barriers to network recruitment that were documented by staff included : networks not being interested in enrolling, Index able to contact network to discuss, network intended to contact the study but never did. For CBOs and NGO who want to implement a similar program, they would not necessarily need to recruit Risk Networks Members prior to the implementation of the intervention sessions, which was conducted as a way to test diffusion. However, ensuring that CBOs have capacity to conduct intervention sessions with a Risk Network Member should be determined during the pre-implementation phase, is advisable.
These limitations not withstanding, results from the STEP into Action intervention indicate sustained efficacy on reduction of HIV risk behaviors and diffusion of this effect to risk network members. Future research is needed to investigate the settings and context in which HIV prevention conversations occur and the types of risk network members who are present at these settings. This could be used to inform where to place interventions and maximize exposure of risk reduction messages and resources to high-risk networks.