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.