Cost-Effectiveness of Combined Sexual and Injection Risk Reduction Interventions among Female Sex Workers Who Inject Drugs in Two Very Distinct Mexican Border Cities

Background

We evaluated the cost-effectiveness of combined single session brief behavioral intervention, either didactic or interactive (Mujer Mas Segura, MMS) to promote safer-sex and safer-injection practices among female sex workers who inject drugs (FSW-IDUs) in Tijuana (TJ) and Ciudad-Juarez (CJ) Mexico. Data for this analysis was obtained from a factorial RCT in 2008–2010 coinciding with expansion of needle exchange programs (NEP) in TJ, but not in CJ.

Methods

A Markov model was developed to estimate the incremental cost per quality adjusted life year gained (QALY) over a lifetime time frame among a hypothetical cohort of 1,000 FSW-IDUs comparing a less intensive didactic vs. a more intensive interactive format of the MMS, separately for safer sex and safer injection combined behavioral interventions. The costs for antiretroviral therapy was not included in the model. We applied a societal perspective, a discount rate of 3% per year and currency adjusted to US$2014. A multivariate sensitivity analysis was performed. The combined and individual components of the MMS interactive behavioral intervention were compared with the didactic formats by calculating the incremental cost-effectiveness ratios (ICER), defined as incremental unit of cost per additional health benefit (e.g., HIV/STI cases averted, QALYs) compared to the next least costly strategy. Following guidelines from the World Health Organization, a combined strategy was considered highly cost-effective if the incremental cost per QALY gained fell below the gross domestic product per capita (GDP) in Mexico (equivalent to US$10,300).

Findings

For CJ, the mixed intervention approach of interactive safer sex/didactic safer injection had an incremental cost-effectiveness ratio (ICER) of US$4,360 ($310–$7,200) per QALY gained compared with a dually didactic strategy. Using the dually interactive strategy had an ICER of US$5,874 ($310–$7,200) compared with the mixed approach. For TJ, the combination of interactive safer sex/didactic safer injection had an ICER of US$5,921 ($104–$9,500) per QALY compared with dually didactic. Strategies using the interactive safe injection intervention were dominated due to lack of efficacy advantage. The multivariate sensitivity analysis showed a 95% certainty that in both CJ and TJ the ICER for the mixed approach (interactive safer sex didactic safer injection intervention) was less than the GDP per capita for Mexico. The dual interactive approach met this threshold consistently in CJ, but not in TJ.

Interpretation

In the absence of an expanded NEP in CJ, the combined-interactive formats of the MMS behavioral intervention is highly cost-effective. In contrast, in TJ where NEP expansion suggests that improved access to sterile syringes significantly reduced injection-related risks, the interactive safer-sex combined didactic safer-injection was highly cost-effective compared with the combined didactic versions of the safer-sex and safer-injection formats of the MMS, with no added benefit from the interactive safer-injection component.

Below:  Cost-effectiveness acceptability curve for the combined interactive safer sex-didactic safer injection intervention in Cd. Juarez

Below:  Cost-effectiveness acceptability curve for the combined interactive safer sex/Safer injection intervention for Ciudad Juarez

Below:  Cost-effectiveness acceptability curve for the combined interactive safer sex and didactic safer injection components of the Mujer Mas Segura intervention in Tijuana

Full article at:   http://goo.gl/RBQD6m

By:  

Jose L. Burgos, Steffanie A. Strathdee

University of California San Diego, Department of Medicine, Division of Global Public Health, La Jolla, California, United States of America

Jose L. Burgos

Universidad Autonoma de Baja California, Facultad de Medicina y Psicología, Tijuana, Baja California, México

Thomas L. Patterson

University of California San Diego, Department of Psychiatry, La Jolla, California, United States of America

Joshua S. Graff-Zivin

University of California San Diego, School of Global Policy and Strategy, La Jolla, California, United States of America

James G. Kahn

University of California San Francisco, Department of Epidemiology and Biostatistics, Philip R. Lee Institute for Health Policy Studies, Global Health Sciences, San Francisco, California, United States of America

M. Gudelia Rangel

Secretaria de Salud de México, Comision de Salud Fronteriza Mexico-Estados Unidos Sección México, Tijuana, Baja California, México

M. Remedios Lozada

Instituto de Servicios de Salud Pública del Estado de Baja California, Mexicali, Baja California, Mexico

Hugo Staines

Universidad Autonoma de Ciudad Juarez, Facultad de Medicina, Ciudad Juárez, Chihuahua, México

  

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Impact of ASUMA Intervention on HIV Risk Behaviors among Puerto Rican Adolescents

The purpose of this manuscript is to assess and compare HIV risk behaviors among early adolescents after a three-year pilot study. 

A total of 135 public and private junior high schools students completed the intervention protocol. A self-administered questionnaire was given at baseline and at the end of the third year (fourth measure). Descriptive and inferential analyses were performed using SPSS 20.0.

About 60% of the students were 14 years old at the fourth measure. The proportion of students that did not report at least one HIV risk behavior at baseline and those that reported any risk behavior at the fourth measure was lower in the intervention group (45.0%) than in the control group (54.5%). The proportion of students that reported at least one HIV risk behavior at baseline and those that did not report any HIV risk behavior at the fourth measure was higher in the intervention group than in the control group (33.3% vs. 8.3%). 

The proportion of students engaging in HIV risk behaviors was higher in the control group than in the intervention group at the fourth measure, suggesting that A Supportive Model for HIV Risk Reduction in Early Adolescence (ASUMA) intervention might be a promising initiative to reduce adolescents' engagement in HIV risk behaviors.

Below:  A Supportive Model for HIV Risk Reduction in Early Adolescence (ASUMA) theoretical framework

Full article at:   http://goo.gl/KbkJP9

By:   Fernandez-Santos DM1, Miranda-Diaz C2, Figueroa-Cosme WI3, Ramon RO4, Mayor AM5, Rios-Olivares E6, Hunter-Mellado RF7.

• 1Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. diana.fernandez@uccaribe.edu.
• 2Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. christine.miranda@uccaribe.edu.
• 3Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. wanda.figueroa@uccaribe.edu.
• 4Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. raul.ramon@uccaribe.edu.
• 5Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. amayorb@hotmail.com.
• 6Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. eddy.rios@uccaribe.edu.
• 7Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. robert.hunter@uccaribe.edu.
• Int J Environ Res Public Health. 2015 Dec 23;13(1). pii: E60. doi: 10.3390/ijerph13010060.

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Relationship Dynamics and Sexual Risk Reduction Strategies among Heterosexual Young Adults: A Qualitative Study of Sexually Transmitted Infection Clinic Attendees at an Urban Chicago Health Center

Few studies have examined risk-reduction alternatives to consistent condom use for HIV prevention among heterosexual young adults. We used qualitative methodology to explore risk reduction strategies and contextual factors influencing attempts to reduce risk in an urban, high morbidity sexually transmitted infection (STI) clinic. 

Focus groups were conducted October–December 2014 with heterosexually identified men (n = 13) and women (n = 20) aged 18–29 seeking STI screening at an urban clinic. Groups were audio recorded, transcribed verbatim, and analyzed for thematic content using Atlas.ti software. Quantitative information included sociodemographics, HIV/STI testing history, and 6-month sexual behaviors. 

Among 33 predominantly African-American participants with a median age of 22, risk-reduction strategies included monogamy agreements, selective condom use with casual and high-risk partners, and frequent HIV/STI testing, though testing was commonly used as a post-hoc reassurance after risk exposure. Many men and women used implicit risk assessment strategies due to mistrust or difficulty communicating. Concurrency was common but rarely discussed within partnerships. Despite attempts to reduce risk, monogamy agreements were often poorly adhered to and not openly discussed. Alcohol and substance use frequently interfered with safer sexual decisions. 

Participants were aware of HIV/STI risk and commonly practiced risk-reduction strategies, but acknowledged faulty assumptions and poor adherence. This work provides insights into risk-reduction approaches that are already used and may be strengthened as part of effective HIV/STI prevention interventions.

Purchase full article at:  http://goo.gl/CgUkhD

By:  Anna L. Hotton, PhD, MPH,^1,4 Audrey L. French, MD,^1,2 Sybil G. Hosek, PhD,³ Sabrina R. Kendrick, MD,^1,2Diana Lemos, PhD, MPH,³ Jennifer Brothers, MPH,³ Stacey L. Kincaid, MPH,¹ and Supriya D. Mehta, PhD, MHS⁴

¹Department of Medicine, CORE Center/John Stroger Hospital of Cook County, Chicago, Illinois.

²Rush University Medical Center, Chicago, Illinois.

³Department of Psychiatry, CORE Center/John Stroger Hospital of Cook County, Chicago, Illinois.

⁴Department of Epidemiology and Biostatistics, University of Illinois Chicago School of Public Health, Chicago, Illinois.

 

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Association of Perceived Partner Non-Monogamy with Prevalent and Incident Sexual Concurrency

OBJECTIVES:

Concurrency is suggested as an important factor in sexually transmitted infection transmission and acquisition, though little is known regarding factors that may predict concurrency initiation. We examined the association between perception of a partner's non-monogamy (PPNM) and simultaneous or subsequent concurrency among at-risk heterosexual young adults in the Los Angeles area.

METHODS:

We used Poisson regression models to estimate the relationship between PPNM and incident concurrency among 536 participants participating in a cohort study, interviewed at 4-month periods during 1 year. Concurrency was defined as an overlap in reported sexual partnership dates; PPNM was defined as believing a partner was also having sex with someone else.

RESULTS:

Participants (51% female; 30% non-Hispanic white, 28% non-Hispanic black, 27% Hispanic/Latino) had a mean age of 23 years and lifetime median of nine sex partners. At each interview (baseline, 4-month, 8-month and 12-month), 4-month concurrency prevalence was, respectively, 38.8%, 27.4%, 23.1% and 24.5%. Four-month concurrency incidence at 4, 8 and 12 months was 8.5%, 10.6% and 17.8%, respectively. Participants with recent PPNM were more likely to initiate concurrency (crude 4-month RR=4.6; 95% CI 3.0, 7.0; adjusted 4-month RR=4.0, 95% CI 2.6 to 6.1).

CONCLUSIONS:

Recent PPNM was associated with incident concurrency. Among young adults, onset of concurrency may be stimulated, relatively quickly, by the PPNM. Programmes which promote relationship communication skills and explicit monogamy expectations may help reduce concurrency.

Purchase full article at:  http://goo.gl/gGCWHc

By:  Sanchez DM1, Schoenbach VJ1, Harvey SM2, Warren JT2, Adimora AA3, Poole C1, Leone PA3, Agnew CR4

• 1Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina, USA.
• 2College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA.
• 3Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina, USA University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
• 4Department of Psychological Sciences, Purdue University, West Lafayette, Indiana, USA. 

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Feasibility of an HIV/STI Risk-Reduction Program for Incarcerated Women Who Have Experienced Interpersonal Violence

HIV and other sexually transmitted infections (STIs) and interpersonal violence (IV; e.g., childhood abuse, partner violence, and rape) victimization are significant and interconnected public health problems facing incarcerated women. We adapted a best-evidence HIV-prevention intervention for women (the Women's CoOp) to address sexual safety among incarcerated women with histories of interpersonal violence victimization. 

The standard Women's CoOp teaches safe sex, substance use harm reduction, and violence prevention information and skills needed to empower women to make more intentional decisions about their safety. We also incorporated strategies to increase affect management, social support, and access to community resources. This resulted in the first trauma-focused HIV-prevention intervention for women that directly addresses the sequelae of IV (such as affect dysregulation in sexual situations) within the context of HIV harm reduction. 

This manuscript describes the rationale, feasibility, acceptability, and pre-post outcomes of this intervention among 14 women nearing release from prison in two state prison systems. Assessments took place at baseline, prior to release, and at 2-, 5-, and 8 months after release. The intervention overall and each of its components were feasible and acceptable. Participants' number of unprotected sexual occasions, post-traumatic stress disorder symptoms, and depressive symptoms decreased significantly from baseline to post-release. Effectiveness in obtaining resources increased significantly from baseline to post-release. 

Because pre-post measurements of outcomes are confounded with incarceration and subsequent release in this preliminary study, a randomized controlled trial is needed to establish the efficacy of this tailored intervention.

Purchase full article at: http://goo.gl/ETlnur

By:  Johnson JE1, Peabody ME2, Wechsberg WM3, Rosen RK4, Fernandes K2, Zlotnick C5.

• 1Brown University, Providence, RI, USA
• 2Brown University, Providence, RI, USA.
• 3RTI International, Durham, NC, USA.
• 4Brown University, Providence, RI, USA Miriam Hospital, Providence, RI, USA.
• 5Brown University, Providence, RI, USA Butler Hospital, Providence, RI, USA Women and Infants Hospital, Providence, RI, USA University of Cape Town, South Africa. 

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