Long-term Follow-up After Voluntary Human Immunodeficiency Virus/Sexually Transmitted Infection Counseling, Point-of-service Testing, and Referral to Substance Abuse Treatment From the Emergency Department

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Abstract

Objectives:

Public health initiatives have lowered human immunodeficiency virus (HIV) transmission risk associated with injection drug use in the United States, making sexual risk behaviors a greater source of transmission. Strategies are therefore needed to reduce these risk behaviors among all emergency department (ED) patients who use drugs, regardless of route of administration. Although recent articles have focused on the opportunity for early HIV detection and treatment through an array of ED screening and testing strategies, the effect of voluntary HIV testing and brief counseling (VT/C) on the sexual behaviors of out-of-treatment drug users over time has not yet been reported.

Methods:

From November 2004 to May 2008, the study screened 46,208 urban ED patients aged 18 to 54 years; 2,148 (4.6%) reported cocaine or heroin use within 30 days, 1,538 met eligibility criteria (Drug Abuse Severity Test [DAST] scores ≥3 and were either English- or Spanish-speaking), and 1,030 were enrolled. These data were obtained in the course of a randomized, controlled trial (Project SAFE) of a brief motivational intervention focused on reducing risky sexual behaviors. Although the intervention itself did not demonstrate any differential effect on the number or percentage of unprotected sexual acts, both control and intervention group participants received baseline VT/C and referral for drug treatment as part of the study protocol. This study is a report of a secondary analysis of cohort data to describe changes in sexual behaviors over time among drug users after the VT/C and referral.

Results:

The mean (±SD) age of enrollees was 35.8 (±8.4) years; 67% were male, 39% were non-Hispanic black or African American, 41% were white non-Hispanic, and 19% were Hispanic. Half injected drugs, and 53% met criteria for posttraumatic stress disorder (PTSD). At baseline testing, 8.8% were HIV-positive on enzyme-linked immunosorbent assay. Follow-ups were conducted at 6 and 12 months, with an attrition rate of 22%. Known HIV-positive patients accounted for 84 of 1,030 cases (8.1%), and 13 new cases were discovered: 7 of 946 at were discovered at the baseline contact (0.74%), 2 of 655 were discovered at 6 months (0.3%), and 4 of 706 (0.57%) were discovered at the 12-month contact. Twelve of the 13 returned for confirmatory testing and were actively enrolled in our infectious disease clinic. For all partners, there was a reduction in the percentage of unprotected sex acts over time (p < 0.0001), with decreases at 6 months versus baseline (odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.60 to 0.83), sustained at 12 months versus baseline (OR = 0.69, 95% CI = 0.58 to 0.82). For the outcome of percentage of sex acts while high, there was also a significant reduction over time (p < 0.0001), with a drop-off at 6 months versus baseline (OR = 0.31, 95% CI = 0.25 to 0.37) that was sustained at 12 months (OR vs. baseline 0.25, 95% CI = 0.20 to 0.30). In an adjusted model, male sex, older age, and HIV positivity predicted significant declines over time in the likelihood of unprotected sexual acts. Older age and higher baseline drug severity predicted significant decreases over time in the likelihood of sex acts while high.

Conclusions:

Voluntary testing and counseling for HIV or sexually transmitted infections, accompanied by referral to drug treatment, for this population of ED cocaine and heroin users was associated with reduction in unprotected sex acts and fewer sex acts while high.

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