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Combined Pharmacological and Behavioral Therapy and HIV Risk
Reduction
Jennifer Schroeder, David Epstein, Katherine Belendiuk, Jessica Willner-Reid, John Schmittner, Kenzie L. Preston
NIDA Intramural Research Program
Supported by NIH NIDA Intramural funds
Substance abuse is a significant vector for HIV transmission.
Transmission can occur at multiple points:
drug procurement exchanging (unprotected) sex for drugs
act of self-administering drugs use of infected equipment
effects of the drugunprotected sex during intoxication
•To determine the effect of combined
methadone maintenance and behavioral
treatments on HIV risk behaviors in
heroin/cocaine users.
•To investigate HIV risk behaviors in a
subpopulation of heroin/cocaine users -
individuals infected with hepatitis C.
Objectives
55% MaleRace: 58% African American 40% White 2% Other
Age: 38 years old Education: 11 years
10 years of Heroin Use; 100% opioid dependent
8 years of Cocaine Use; 65% DSM IV cocaine dependent
<10% HIV positive
Treatment Population
Target heroin use - Methadone Maintenance
Target cocaine use - Contingency management - reinforced
cocaine abstinenceCognitive Behavioral Therapy - four
specific skills taught:Coping skills to deal with stressRelapse prevention skills to deal with craving Development of alternative (non-drug)
reinforcersHIV Risk Reduction Education
Combination
Single
Single
Control
CognitiveBehavioral
SocialSupport
ContingencyManagement
NoncontingentControl
Combination Treatment
Baseline InterventionPost Intervention
Maintenance
5 weeks 12 weeks 8-12 weeks
Study Time Line
Counseling
Behavioral Intervention
Informed consentand screening
Methadone stabilization 70 - 100 mg/day
weekly individual
Randomization
HIV Risk Behavior Questionnaire every 2 weeks• •
•
•
HIV Risk Behavior Questionnaire
Internally developed questionnaire modified from that used in the ALIVE study (Vlahov et al., 1991).
Drug-related behaviors how often injected any kind of drughow frequently injected with shared needles
Sexual behaviors how frequently had unprotected sex how frequently traded sex for money, drugs or
gifts.
Possible responses: none, less than 4 times per month, once per week, 2-6 times per week, daily, 2 or more times a day.
Responses were dichotomized to none vs. some (i.e., any occurrence of the behavior).
HIV Risk Behaviors
0
20
40
60
80
100
InjectionDrug Use
ShareNeedles
UnprotectedSex
Trade Sex forMoney or Drugs
% R
epo
rtin
g B
eha
vior
Before Treatment96%
57%
31% 29%
N=81
HIV Risk Behaviors
0
20
40
60
80
100
InjectionDrug Use
ShareNeedles
UnprotectedSex
Trade Sex forMoney or Drugs
% R
epo
rtin
g B
eha
vior
Before TreatmentAfter Treatment
96%
49%57%
5%
31%
4%
29%
2%
N=81
0
20
40
60
80
100
CBT+CM
CBT CM Control
% R
ep
ort
ing
Be
ha
vio
r
0
20
40
60
80
100
CBT+CM
CBT CM Control
% R
ep
ort
ing
Be
ha
vio
r
Before
After
0
20
40
60
80
100
CBT+CM
CBT CM Control
% R
ep
ort
ing
Be
ha
vio
r
0
20
40
60
80
100
CBT+CM
CBT CM Control
% R
ep
ort
ing
Be
ha
vio
r
Frequencies of self-reported HIV risk behaviors by treatment group
CBT - Cognitive Behavioral Therapy; CM - Contingency Management Therapy
Injection Drug Use Share Needles
Unprotected Sex Trade Sex for Money or Drugs
**
*
*
Methadone maintenance augmented with behavioral
interventions has broad beneficial effects in
reducing risky behaviors.
Cognitive behavior therapy enhanced with HIV
Risk education had limited added benefit over
standard treatment.
Are treatment effects on risky behaviors
different in infected and non-infected
populations?
Risky Behaviors in HCV-infected Polydrug
UsersParticipants:647 polydrug (heroin/cocaine) users tested for HCV antibodies on admission55% HCV positive (n = 356); 45% HCV negative (n =
291) most were unaware of their HCV status at the time
of testing
Treatment:Methadone Maintenance Contingency management - reinforced cocaine/heroin
abstinence.HIV risk reduction education was incorporated in
individual counselingfor all participants.
HIV Risk-taking Behavior Scale (HRBS; Darke, et al., 1991)Two subscales: Drug-related risk behavior; Sexual
risk behavior Completed every two weeks
0
2
4
6
8
10
12
0 4 8 12 16 20 24 28
HIV Risk-taking Behavior Scale
TotalScore
Treatment Week
*
HCV negativeHCV positive
Maximum possible score = 60; higher score = more risky behavior
HIV Risk-taking Behaviors and Hepatitis C Infection
Intake:F1, 645 = 86.6, p<.001
0
2
4
6
8
10
12
0 4 8 12 16 20 24 28
HIV Risk-taking Behavior Scale
TotalScore
Treatment Week
*
*
* HCV negativeHCV positive
Maximum possible score = 60; higher score = more risky behavior
HIV Risk-taking Behaviors and Hepatitis C Infection
HCV status: F1, 645 = 10.3, p< .001HCV status X Time: F15, 6229 = 10.3, p< .0001
Treatment Week
0
1
2
3
4
5
6
7
8
0 4 8 12 16 20 24 28
Drug Risk Subscale
SubscaleScore
*
*
*
* **
0
1
2
3
4Times Injected
0
1
2
3
4
0 5 10 15 20 25 30
Did Not Clean Needles
Week
Representative Individual Items
HIV Risk-taking Behavior Scale
HCV negativeHCV positive
Maximum possible score: subscale = 30; individual items = 6; higher score = more risky behavior
N = 647HCV status: F1, 645 = 552.5, p< .0001
N = 418HCV status: F1, 412 = 11.3, p< .0008
HCV status: F1, 645 =23.9, p< .001Time: F15, 6147 =76.9, p< .0001 HCV stat X Time: F15, 6147 =23.9, p< .0001
0 5 10 15 20 25 30Week
0
1
2
3
4
5
6
7
8
0 4 8 12 16 20 24 28
Sex Risk Subscale
SubscaleScore
Sex with How Many Partners
0
1
2
3
4 No Condoms with Casual Partners
Week
Representative Individual Items
HCV negativeHCV positive
HIV Risk-taking Behavior Scale
Treatment Week
Maximum possible score: subscale = 30; individual items = 6; higher score = more risky behavior
N = 647HCV status: NS
N = 480HCV status: F1, 477= 19.9, p< .0001
HIV status: F1, 645 = 9.8, p< .01Time: F15, 6144 = 18.9, p< .0001 HIV status X Time: NS
0
1
2
Conclusions
• HIV-risk behaviors decreased in polydrug users
receiving combined pharmacological and
behavioral treatments.
• Polydrug users who were already infected with
hepatitis C reported a steeper decline in risky
behaviors than non-infected patients.