HIV, HCV, and other infections present a widespread and serious threat to the health of substance users; it is imperative to bring proven HIV behavioral interventions to community substance abuse treatment programs. However, these interventions can only be useful if they are acceptable, feasible, and effective within the daily operations of programs. Over the past decade, within the CTN framework, five large-scale, multisite HIV/HCV protocols, conducted in community treatment programs have addressed questions about effectiveness and feasibility of HIV behavioral interventions. One protocol provided a national profile of existing HIV and HCV services and regulations from which to make strategic plans. Two protocols focused on sexual risk reduction in outpatient programs. One protocol focused on HIV testing, risk reduction, and linkage to ongoing treatment for IDUs in inpatient detoxification. Aided by the inclusion of HIV risk behavior assessments in every CTN protocol, other CTN investigators have tracked the effects of their non-HIV-centered interventions on HIV risk behavior.
A few conclusions should be emphasized from the CTN HIV experience. First, with focused training and support, brief evidence-based HIV interventions can be integrated into the daily substance abuse treatment work of frontline providers. All interventions were delivered by frontline providers. It is noteworthy that, in all three HIV protocols (i.e., CTN0017, CTN0018, CTN0019), rates of frontline counselor adherence to the intervention exceeded 80%. However, participant attendance was problematic. For example, in the HIV/STD Safer Sex Skills trials, intervention completion rates were slightly above 50% (men) and slightly below 50% (women). Second, within the CTN multisite trial infrastructure, the effectiveness of HIV interventions can be tested to address the question of whether results from community effectiveness trials can be as robust as those from original single site efficacy studies, an important empirical issue. For the women’s Safer Sex Skills trial, it was possible to compare the effect size obtained for SSSB in this community trial with that of the original efficacy study. The CTN effect size (d
= .42) was very similar to that (d
= .46) of the original efficacy study (63
), as reported in Prendergast and colleagues’ meta-analysis (19
). It is relevant that in both the SSSB and men’s REMAS trials effect sizes exceeded those reported for sexual risk behavior by Prendergast et al. (19
). However, these effect sizes are still only considered small to medium. Third, within the large and diverse samples of these trials, compelling clinical and/or scientific questions can be answered in secondary analyses. Fourth, while some trials demonstrated superiority of enhanced HIV interventions, other trials obtained equal effects for TAU and enhanced conditions. These mixed results raise questions about the durability of enhanced interventions in community programs, already facing resource and funding constraints.
The question of whether CTN HIV effectiveness research interventions became part of daily practice in community substance abuse programs, especially those in which the research was conducted, is a crucial one. Multiple dissemination efforts of CTN HIV research findings, interventions, and materials have been made to providers in the CTN and general community. Dissemination efforts have included traditional methods such as publications in academic journals and presentations at national and international professional conferences and meetings. It has also included a publication in a trade journal that is popular among substance abuse treatment counselors (45
). Representation on websites has also enhanced visibility and promoted dissemination. The REMAS and SSSB interventions were identified as promising, evidence-based HIV prevention interventions by the CDC, and listed on the CDC Diffusion of Effective Behavioral Interventions website (see http://www.cdc.gov/hiv/topics/research/prs/
). An online course is now being developed with these two interventions that will enable substance abuse treatment providers to earn continuing education credits free of charge.
The CTN also supports a web-based dissemination library (http://ctndisseminationlibrary.org/
). As of January 2011 there have been 574 visits to the REMAS manual webpage, 674 visits to the SSSB manual web-page, 247 visits to the Therapeutic Alliance Intervention manual webpage, and 128 visits to the HIV and HCV Counseling and Education manual webpage. SSSB is now being tailored for use with other community treatment populations, including pregnant women (79
) and adolescent girls (80
Despite these promising dissemination activities, uptake of CTN HIV protocol interventions in community treatment programs remains mixed and a crucial limitation of the work. In CTN0010 alone, uptake was robust; four of the five participating clinics are using buprenorphine/naloxone for opioid-dependent youth. However, for other CTN protocols, there is limited evidence of intervention uptake, wholesale, into host community treatment programs after the end of the research. A survey study conducted with host programs that participated in the Safer Sex Skills trials explored the issues of uptake, and barriers to and promoters of sustainability. While clinicians and administrators rated the interventions very favorably (81
), none of the programs had adopted either intervention in entirety (82
). However, a few programs reported using a subset of the modules that make up the interventions. The primary reasons given for low uptake were “lack of staff time,” “competing treatment priorities,” and “inadequate mechanism for reimbursement.” While lack of uptake is an important limitation of the work, it is an ongoing challenge to HIV researcher and provider partners to develop strategies that will enhance adoption of research interventions as an integral part of their research program from the outset (83
Taken together, the limitations of low-intervention completion rates, modest effect sizes, and lack of adoption would seem to beg for cost-effective, less-cumbersome intervention delivery methods in future HIV intervention effectiveness research. Thus, technologically innovative interventions, using computers or cell phones as delivery platforms, and minimizing provider resource burden, might improve upon these findings (84
). In addition, important gaps in the CTN HIV portfolio also press for future projects, in priority areas identified by the National HIV/AIDS Strategy for the United States (www.WhiteHouse.gov/ONAP
), at the intersection of HIV and substance use. Future research is needed to (1) reduce new HIV transmission through tailored HIV risk reduction interventions with HIV high-risk populations, including stimulant-using men-who-have-sex-with-men, racial/ethnic minority substance users, and substance-using adolescents; (2) reduce new transmission through tailored HIV risk reduction interventions with HIV seropositive substance users; (3) reduce new transmission by implementing pre-and/or post-exposure medication among HIV high-risk populations; (4) improve health outcomes for people living with HIV by integrating substance abuse treatment into HIV primary care settings and integrating HCV, STI, and other infectious disease services into substance abuse treatment programs; and (5) reduce HIV health disparities by tailoring HIV risk reduction, outreach and linkage, and adherence programs to the racial/ethnic groups disproportionately impacted by the epidemic.