Integrating Sexual Risk Discussion Into Substance Use Disorder Counseling

This study looked at whether a clinician training program for enhancing patient-counselor communication about sexual risk behavior in those with substance use disorder was effective.

Results from a study published in the Journal of Substance Abuse Treatment support the efficacy of a clinician training program in enhancing patient-counselor communication about sexual risk behavior. In a cohort of counselors for substance use disorders (SUDs), those who received specialized training on sexual risk were more likely to discuss sex with their patients. However, counselor training condition had no demonstrable effect on patient-reported risky sexual behavior.

Patients with SUDs are more likely to engage in high-risk sexual behaviors, such as condomless sex and transactional or commercial sex. In turn, these behaviors amplify the risk of relapse and disease transmission. To determine whether SUD counseling can effectively reduce sexual risk, investigators conducted a nested 2X2 factorial repeated measures trial, in which SUD counselors were randomized to receive either “Basic” or “Enhanced” training in talking to patients about sex.

After baseline assessment, patients were randomized to receive either no feedback or a Personalized Feedback Report (PFR) based on self-reports of sexual behavior. Thus, patients were randomized to a total of 4 study conditions: (1) no PFR and counselor with basic training; (2) no PFR and counselor with enhanced training; (3) PFR and counselor with basic training; and (4) PFR and counselor with enhanced training.

Patients met with counselors regularly over 6 months. The primary outcome measure was whether patients reported talking about sex with their counselors in the past 90 days. These measures were assessed by self-reporting at the 3- and 6-month follow-up assessments. Follow-up assessments also captured the number of unsafe sex occurrences, number of sexual partners, sex under the influence of substances, and condom barrier use. 

A total of 467 patients were enrolled, among whom 52% were men and 48% were women. Mean age was 38.5±11.5 years; 76% were White; 12% were Black; and 10% were Latino/a.

At baseline, 32% of patients indicated that they were not currently sexually active. Both counselor training and PFR condition had a substantial effect on the primary study outcome. At the 6-month time point, patients were significantly more likely to report discussing sex with counselors in the enhanced condition compared withal counselors in the basic condition (P <.05).

Similarly, patients who received a PFR at baseline were more likely to discuss sex during counseling than patients who did not receive a PFR (P <.05). However, neither counselor nor PFR condition affected the number of unsafe sex occurrences, the number of sexual partners, or sex under the influence, as reported by patients.

Per these data, counselor- and patient-level interventions had a direct effect on counselor-patient communication without affecting sexual behavior itself.  “A key implication of our findings is that counselor’s abilities need to be strengthened to facilitate such discussions into behavior change,” authors wrote. Future research is necessary to identify more effective means of integrating sexual risk reduction into SUD treatment.


Hatch MA, Wells EA, Masters T, et al. A randomized clinical trial evaluating the impact of counselor training and patient feedback on substance use disorder patients’ sexual risk behavior. J Subst Abuse Treat. Published online June 16, 2022. doi:10.1016/j.jsat.2022.108826