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Combined Pharmacological and Behavioral Therapy and HIV Risk Reduction

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.

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Combined Pharmacological and Behavioral Therapy and HIV Risk Reduction

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  1. 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

  2. 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 drug unprotected sex during intoxication

  3. Objectives • 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.

  4. Treatment Population 55% Male Race: 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

  5. Combination Treatment Target heroin use - Methadone Maintenance Target cocaine use - Contingency management - reinforced cocaine abstinence Cognitive Behavioral Therapy - four specific skills taught: Coping skills to deal with stress Relapse prevention skills to deal with craving Development of alternative (non-drug) reinforcers HIV Risk Reduction Education Cognitive Behavioral Social Support Combination Single Contingency Management Single Control Noncontingent Control

  6. 70 - 100 mg/day stabilization Methadone Counseling Behavioral Intervention HIV Risk Behavior Questionnaire • • every 2 weeks Study Time Line Post Intervention Maintenance Intervention Baseline Informed consent and screening • weekly individual • Randomization 5 weeks 12 weeks 8-12 weeks

  7. 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 drug how 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).

  8. HIV Risk Behaviors 100 96% Before Treatment 80 60 % Reporting Behavior 57% 40 31% 29% 20 0 Unprotected Sex Trade Sex for Money or Drugs Injection Drug Use Share Needles N=81

  9. HIV Risk Behaviors 100 96% Before Treatment 80 After Treatment 60 % Reporting Behavior 57% 49% 40 31% 29% 20 5% 4% 2% 0 Unprotected Sex Trade Sex for Money or Drugs Injection Drug Use Share Needles N=81

  10. Frequencies of self-reported HIV risk behaviors by treatment group Injection Drug Use Share Needles 100 100 * 80 80 60 60 * % Reporting Behavior % Reporting Behavior 40 40 20 20 0 0 CBT +CM CBT CM Control CBT +CM CBT CM Control Unprotected Sex Trade Sex for Money or Drugs 100 100 80 80 60 60 * % Reporting Behavior % Reporting Behavior 40 40 * 20 20 0 0 Before CBT +CM CBT CM Control CBT +CM CBT CM Control After CBT - Cognitive Behavioral Therapy; CM - Contingency Management Therapy

  11. 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?

  12. Risky Behaviors in HCV-infected Polydrug Users Participants: 647 polydrug (heroin/cocaine) users tested for HCV antibodies on admission 55% HCV positive (n = 356); 45% HCV negative (n = 291) most were unaware of theirHCV status at the time of testing Treatment: Methadone Maintenance Contingency management - reinforced cocaine/heroin abstinence. HIV risk reduction education was incorporated in individual counseling for 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

  13. HIV Risk-taking Behaviors and Hepatitis C Infection HIV Risk-taking Behavior Scale 12 * Intake: F1, 645 = 86.6, p<.001 10 8 HCV negative HCV positive T ota l 6 Score 4 2 0 0 4 8 12 16 20 24 28 Treatment Week Maximum possible score = 60; higher score = more risky behavior

  14. HIV Risk-taking Behaviors and Hepatitis C Infection HIV Risk-taking Behavior Scale 12 HCV status: F1, 645 = 10.3, p< .001 HCV status X Time: F15, 6229 = 10.3, p< .0001 * 10 8 HCV negative * HCV positive T ota l 6 Score * 4 2 0 0 4 8 12 16 20 24 28 Treatment Week Maximum possible score = 60; higher score = more risky behavior

  15. 4 3 2 1 0 HCV negative HCV positive HIV Risk-taking Behavior Scale Representative Individual Items Times Injected Drug Risk Subscale N = 647 HCV status: F1, 645 = 552.5, p< .0001 8 HCV status: F1, 645 =23.9, p< .001 Time: F15, 6147 =76.9, p< .0001 HCV stat X Time: F15, 6147 =23.9, p< .0001 * 7 6 5 * Subscale 4 4 Score Did Not Clean Needles 3 N = 418 HCV status: F1, 412 = 11.3, p< .0008 * 3 * * 2 * 2 1 1 0 0 4 8 12 16 20 24 28 0 Treatment Week 0 5 10 15 20 25 30 Week Maximum possible score: subscale = 30; individual items = 6; higher score = more risky behavior

  16. 2 1 0 HCV negative HCV positive 4 3 2 1 0 0 5 10 15 20 25 30 HIV Risk-taking Behavior Scale Representative Individual Items Sex with How Many Partners Sex Risk Subscale N = 647 HCV status: NS 8 HIV status: F1, 645 = 9.8, p< .01 Time: F15, 6144 = 18.9, p< .0001 HIV status X Time: NS 7 6 5 Subscale 4 Score No Condoms with Casual Partners 3 N = 480 HCV status: F1, 477= 19.9, p< .0001 2 1 0 0 4 8 12 16 20 24 28 Treatment Week Week Week Maximum possible score: subscale = 30; individual items = 6; higher score = more risky behavior

  17. 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.

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