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OCTOBER/NOVEMBER 2006
News and Literature Reviews
An HIV/STD Risk Reduction Intervention for Male Prison Releasees: A glass two-thirds full. Many correctional facilities provide HIV/STD risk reduction counseling to inmates but few, if any, extend such interventions beyond release -when releasees have the greatest opportunity to engage in the very behaviors they are being trained not to do. Project START, a multisite trial funded by the Centers for Disease Control and Prevention (CDC), compared a single session pre-release HIV/STD risk reduction counseling intervention with a pre-release and post-release series of sessions focusing not only on risk behaviors but also on community re-entry needs. The single session intervention was conducted two weeks prior to release and the multi-session intervention consisted of two pre-release sessions plus four sessions conducted 1, 3, 6 and 12 weeks after release. Both employ techniques of motivational interviewing, prevention case management and harm reduction. Participants were incarcerated men age 18 to 29 years, housed at state prisons in California, Mississippi, Rhode Island or Wisconsin and expected to be released to an unrestricted environment within 14 to 60 days of study entry. A total of 522 men were enrolled and released. Half were Black, non-Hispanic, over 90% were single and unprotected sex in the three months prior to incarceration prior to incarceration was reported by 87.6%. Only 11 men reported sex with a man prior to incarceration and 2 men were known to be HIV-infected. Two thirds (67%) of those randomized to the multi-session intervention received five or more of the sessions. There were no differences in reported risk behaviors between the study arms at weeks 1 and 12 post-release. At week 24, statistically significant differences were observed in reported rates of unprotected vaginal or anal sex during the most recent encounter and with any partner favoring the multi-session intervention. Of the men assigned this intervention, 68% reported these risk behaviors compared to 78% of those assigned to the single-session arm (odds ratio=0.40; 95% CI=0.18, 0.88). Interestingly, the multi-session intervention had the greatest effect at reducing reported unprotected sex with a main sex partner (someone the participant felt an emotional attachment or commitment to). In contrast, the intervention had no significant effect on risk behavior with non-main partners. Re-incarceration was common with 44% returning to prison or jail by six months. At week 12 but not 24, the multi-session group had significantly higher re-incarceration rates. These results demonstrate the relative effectiveness of a risk reduction intervention that spans the periods of incarceration and release. Yet, they also highlight the difficulty of positively modifying behavior in this setting as 68% of those in the 'successful' arm of the study reported unprotected sex. Further, all behaviors were self-reported and it is conceivable that those receiving the more intensive intervention may have felt a greater need to provide socially desirable responses - unfortunately, biological specimens to test for STDs were not included in the overall study protocol. Nonetheless, this is an important study, lessons from which can be applied to the design of existing or planned risk reduction programs for prison/jail releasees, as well as future research investigations. Relative Efficacy of a Multisession Sexual Risk-Reduction Intervention for Young Men in 4 States. Wolitski RJ et al. American Journal of Public Health. 2006;96(10):1854-61. US HIV Treatment Guidelines Updated A US Department of Health and Human Services (DHHS) panel on October 10th announced important revisions to the department's Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Reflecting the findings of several from recently reported antiretroviral clinical trials, the guidelines have expanded the "preferred" options for initial treatment of HIV infection by adding the ritonavir (Norvir) boosted protease inhibitors (PI) atazanavir (Reyataz) and fosamprenavir (Lexiva) to lopinavir/ritonavir (Kaletra) and efavirenz (Sustiva) as favored regimen anchors. These drugs are to be used with duel nucleoside reverse transcriptase (NRTI) combinations and the guidelines now list both tenofovir/emtricitabine (Truvada) and zidovudine/lamivudine (Combivir) as the only preferred companion NRTIs (see table below). Several alternative options, considered inferior by the panel, are listed as they may be preferable in some circumstances. In general, these revisions move these guidelines closer to those issued by the International AIDS Society-USA (http://www.iasusa.org/pub/), which tend to recommened classes of antiretrovirals rather than specific antiretroviral agents to first-line therapy. In addition to the revisions to the recommended HIV therapies for treatment-naive patients, the guidelines have added information regarding the use of darunavir (Prezista) and tipranavir (Aptivus) and information on expanded access to the investigational medications TMC-125, a non-nucleoside reverse transciptase inhibitor (NNRTI) and MK-0518, an inhibitor of the HIV integrase. The US Department of Health and Human Services. October 2006. Available at http://aidsinfo.nih.gov/.
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