Couples-based intervention has impact on HCV incidence and risky sexual behaviour among drug-involved couples in Kazakhstan

A couples-based risk reduction intervention reduced hepatitis C virus (HCV) incidence and levels of sexual risk-taking among drug-involved couples, investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. The study was conducted in Kazakhstan, which has one of the fastest growing HIV epidemics in the world and a high prevalence of injecting drug use.

An international team of investigators recruited 300 drug-involved heterosexual couples who were randomised to participate in a focused sexual health and injecting drug use risk reduction programme or a general wellness programme. HCV incidence was lower among participants in the risk reduction arm, who were also less likely to report unprotected sex. Risky injecting practices were reduced in both study arms.

The authors note this is the first randomised controlled trial “in which a couple-based HIV/HCV/STI [sexually transmitted infection] intervention demonstrated effect for both biological and behavioral endpoints.”

High rates of unprotected sex and unsafe injecting practices have led to epidemics of HIV and HCV among people who inject drugs in Kazakhstan.

Research has found that couple-based behavioural interventions can reduce sexual and drug-related risk behaviours. An international research team therefore designed a randomised controlled trial to see if such an intervention could reduce rates of new HIV, HCV, and STIs and reduce risky sexual and drug use behaviours among drug-involved couples in Almaty, Kazakhstan.

Between 2009 and 2012, a total of 300 heterosexual couples were recruited via word of mouth. They were randomised to participate in the focused risk reduction sessions or the general wellness programme.

The risk reduction intervention was based on an HIV prevention intervention designed and tested using couples in New York City. Its core components focused on strategies to reduce HIV, HCV and STI risk; communication, negotiation and problem-solving skills that couples could use together to reduce sexual and drug-related risk; the development of skills in condom use and learning about pleasurable safer sex practices; the cleaning of injecting equipment and strategies for obtaining new injecting equipment.

The wellness programme had components on diet, fitness, access to health and drug treatment services, stress reduction techniques and the setting of personal goals.

Both interventions included sessions on overdose prevention and response.

At least one partner in each couple reported injecting drug use in the previous three months. The median age of participants was 35 years and 87% were married. Almost half reported having insufficient money for food in the previous three months. At baseline, 26% of participants were identified as HIV positive, 77% were positive for HCV and 6% had a STI.

Incidence of new HCV infections was 7.4 per 100 person-years among individuals in the risk reduction arm compared to 20 per 100 person-years in the control arm. Participants in the intervention arm therefore had a significant 69% lower incidence of HCV infection compared to people in the wellness programme.

Incidence of HIV and STIs was also lower in the risk reduction arm compared to the control arm (51% and 37%, respectively), but the differences between the two groups were not significant.

Participation in the risk reduction programme had a positive impact on sexual risk behaviour. Participants in the risk reduction arm had a 42% lower incidence of unprotected vaginal sex acts compared to individuals in the wellness programme and were more than twice as likely to report consistent condom use (OR = 2.30 95% CI 1.33-4.00).

However, reductions in sexual risk were mainly seen in the first three months of follow-up. “These findings demonstrate the strength of the risk reduction intervention in reducing risky sexual behaviors early on, and suggest that additional effort such as booster sessions may be helpful in maintaining changes in behavior change over time,” comment the authors.

Participants in both the risk reduction and wellness programmes reported substantial reductions in rates of needle sharing and unsafe injecting over the follow-up period, and there were no significant differences between the study arms.

“We speculate that this reduction in drug risks can be attributed to the overdose prevention and health-related content that was included in both arms of the study,” write the investigators.

They call for further research to see how changes in sexual behaviour associated with a risk reduction programme can be maintained in the longer term.