DRUG TREATMENT AS HIV PREVENTION
Does Treatment for Methamphetamine Dependence Reduce HIV Risk Behavior in non-MSM Treatment Samples?
Richard A. Rawson, Ph.D., Valerie Pearce, M.P.H., Rachel Gonzales, Ph.D., and Julie Brummer
Treatment for methamphetamine (MA) dependence has been shown to be an important HIV risk-reduction strategy for MA-dependent men who have sex with men (MSM). However, there are minimal data on the generalizability of this finding to broader treatment populations who do not exclusively include MSM. This study examines the extent to which treatment for MA dependence is associated with a reduction in HIV-related risk behaviors among three samples of heterogeneous MA users. Data from three clinical trials of MA users were analyzed: two MA pharmacotherapy trials (ondansetron and bupropion) conducted as part of the National Institute on Drug Abuse Methamphetamine Clinical Trials Group (MCTG) (N=320) and a Substance Abuse and Mental Health Services Administration-funded clinical behavioral trial called the Methamphetamine Treatment Project (MTP) (N=977). All participants were enrolled in an outpatient behavioral treatment program, either as a “platform” intervention for a pharmacotherapy trial (MCTG) or as a primary psychosocial treatment (MTP). Data specifically assessed HIV-related risk behavior, including injection drug use and sexual practices (defined as unprotected sexual intercourse with multiple sex partners and/or anal intercourse) using the HIV Risk Behavior Scale (MCTG) or AIDS Risk Assessment (Texas Christian University) (MTP), at the time of treatment entry and at termination from the treatment at 8–12 weeks for those in the MCTG and at 16 weeks for those in the MTP. Data from the MCTG study indicated that at baseline 68 individuals (21.2 percent) reported injection within the previous 30 days. At discharge there was a reduction to 24 (10.3 percent). Of the sample that engaged in unsafe sexual activity in the last 30 days at admission (n=199), there was a significant reduction in the unsafe sexual behavior mean composite score (5.28 to 4.4; t=2.544, p<.05). In the MTP trial, injection within the past 30 days decreased from 128 individuals (13.1 percent) at baseline to 53 individuals, or 5.4 percent, at discharge. Unsafe sexual behavior was reported by 612 individuals (62.6 percent) at baseline and decreased over the treatment period to 445 individuals (45.5 percent) at discharge. The sum average risk score (number of times they engage in risky behaviors) for the heterosexual population is 23.06 at baseline and 10.18 at discharge. Additional results are presented on the relationship between time in treatment and reduction in MA use with the magnitude of the reduction of HIV risk behavior. Furthermore, in the MTP study data at 3-year followup will be presented.
Combined Pharmacological and Behavioral Therapy and HIV Risk Reduction
Kenzie L. Preston, Ph.D., Jennifer R. Schroeder, Ph.D., David H. Epstein, Ph.D., and
Annie Umbricht, M.D.
Cocaine use is associated with injecting and sexual HIV risk behaviors. This study was a randomized controlled trial testing the combination of two behavioral interventions for cocaine dependence and HIV risk behaviors among dually (cocaine and heroin) dependent outpatients. Methadone maintenance was augmented with contingency management (CM), cognitive-behavioral therapy (CBT), both (CM+CBT), or neither. CM rapidly reduces cocaine use, but its effects subside after treatment, while CBT produces reductions that emerge 6–12 months after treatment ends. Combined, the two treatments might be complementary. The study sample (n=81) was 52 percent female, 70 percent African-American, and 37.9±7.0 years old. The proportions reporting HIV risk behaviors at intake were 96.3 percent (78/81) injection drug use, 56.8 percent (46/81) sharing needles, 30.9 percent (25/81) unprotected sex, and 28.4 percent (23/81) trading sex for money or drugs. The proportions who no longer reported behaviors at the study exit were 48.7 percent (38/78) injection drug use, 91.3 percent (42/46) sharing needles, 88 percent (22/25) unprotected sex, and 91.3 percent (21/23) trading sex for money or drugs. Participants receiving CM+CBT were more likely to report the cessation of unprotected sex relative to controls (OR=5.44, 95-percent confidence interval 1.14–26.0, p=0.034), but this effect was reduced by adjusting for drug-negative urines. These results suggest the broad beneficial effects of methadone maintenance augmented with behavioral interventions for reducing HIV risk behaviors.
Behavioral Interventions for HIV Risk Reduction and HIV Prevention: An International Perspective
Marek C. Chawarski, Ph.D.
The presentation describes our initial work in Malaysia comparing a behavioral counseling platform only with counseling combined with naltrexone or buprenorphine maintenance and our current work developing and testing behavioral drug and HIV risk-reduction counseling that can be provided by available nursing and other health personnel in developing countries. In the initial study, HIV risks were reduced in all three groups, buprenorphine was associated with significantly better drug-related outcomes, and sexual risk behaviors were not reduced in any of the three groups. Based on the research outcomes and clinical feedback obtained from studies conducted in the United States and internationally, we have developed an improved integrated drug abuse and HIV-risk reduction intervention. This new intervention is founded on the principles of cognitive-behavioral treatments and utilizes evidence-based counseling approaches based on the research findings in cognitive and health psychology on effective behavior change. We demonstrate that medical personnel (nurses) available in developing countries could be trained to provide this type of counseling. Our data also show preliminary improved efficacy as compared with the limited psychosocial treatment typically provided. The treatment is currently being implemented and tested in various research and clinical settings in Asia, the Middle East, and the United States.