HIV RISK REDUCTION AND SUBSTANCE ABUSE TREATMENT

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HIV RISK REDUCTION AND SUBSTANCE ABUSE TREATMENT

• George E. Woody, M.D.
• Department of Psychiatry, University of
  Pennsylvania and Department of Veterans Affairs,
  Philadelphia, PA

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Overview of HIV Rise in NYC Among IDUs (Kreek et
al)

• 1978-1984 Increase from 0 to about 55 overall
• Leveling off at 50-55, then a slow decrease
  beginning around 1992

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HIV-1 Infection in Intravenous Drug Users In New
York City 1983 - 1984 Study Protective Effect
of Methadone Maintenance (Kreek et al)

• 50 60 of untreated, street heroin addicts test
  positive for HIV-1
• 9 of methadone continuously maintained since
  lt1978 test positive

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Six Year HIV Infection Rates by Treatment Status
at Time of Enrollment In Study
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Methadone Levels Study
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Reasons for HIV Risk Reduction in Methadone
Maintenance

• Abstinence
• If dont stop drug use completely almost always
  reduce it substantially (e.g. reduction in
  severity of the target symptom)
• Fewer injections
• Exposure to risk reduction counseling and other
  information in treatment program

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NIDA Cocaine Collaborative Treatment
StudyCrits-Christoph et al

• Random assignment to
• group drug counseling alone (GDC)
• individual drug counseling (IDC) plus GDC
• cognitive therapy (CT) plus GDC
• supportive-expressive therapy (SE) plus GDC.

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• 6-month active phase and a 3-month booster phase.
  
• GDC sessions were 1.5 hours weekly throughout the
  6-month active phase.
• Oriented toward helping patients stop cocaine use
  and
• Facilitating participation in 12-step programs
• Included education about HIV risk reduction.

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• Individual therapy sessions for IDC, CT and SE
  therapy were
• 50 minutes twice weekly for the first 12 weeks
• Then weekly during weeks 13-24.
• Monthly individual sessions held during the
  booster phase in months 7-9.

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• Patients recruited by advertisements, from
  substance abuse treatment programs, referrals
  from friends or acquaintances, mental health
  centers, and private mental health providers.
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• Patients 18-60 years of age, principal DSM-IV
  diagnosis of cocaine dependence that was current
  or in early partial remission, and had used
  cocaine gt1 day in the past 30 days.

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Exclusion criteria

• Unstable living situations
• Inability to give informed consent
• Opioid or polysubstance dependence (current or in
  early remission)
• Major psychiatric disorder other than cocaine
  dependence
• Needing to be maintained on psychotropic
  medication
• Life-threatening or unstable medical condition
• Serious legal problems such as impending
  incarceration, living in a halfway house, being
  in a hospital for more than 10 of the past 30
  days
• Scheduling problem that made it difficult to keep
  regular appointments.

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Exclusion criteria (contd)

• Patients invited for an intake visit after being
  screened by telephone
• At intake visit study explained and informed
  consent obtained.
• Patients then began a screening/stabilization
  phase designed to select those with enough
  motivation to participate in an outpatient study.
  
• Patients required to attend three visits within
  14 days, including one group session and two case
  management sessions as a test of their ability to
  comply with study requirements.

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• - 2197 patients screened
• - 1771 met basic inclusion criteria and
  scheduled for an intake visit,
• - 937 reported for intake
• - 870 began orientation
• - 487 completed required number of appointments
  randomized.

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Five sites participated

• Western Psychiatric Institute and Clinic
• University of Pennsylvania
• Brookside Hospital (Nashua, NH)
• Massachusetts General Hospital
• McLean Hospital (Belmont, MA).

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Randomized patients had

• Average age of 34
• Lived alone (70),
• 13 years of education
• Were employed (60)
• Male (77) Caucasian (58)
• 40 African-American 2 were Latino/a.

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• Crack smoking the most common (79)
• 19 intranasal cocaine
• 2 used intravenously.
• Average patient used cocaine for 7 years and
  reported 10 days of cocaine use and 7 days of
  alcohol use in the last month.

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• Following randomization, patients kept about half
  their scheduled appointments during the six-month
  active treatment phase.
• HIV risk measured by RAB
• A self-report instrument that takes 10-15 minutes
  to complete
• Measures behaviors that are associated with HIV
  risk.
• Focuses on drug use during the past 30 days, and
• Injection and sexual risk during the past 6
  months

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• For example, in response to the question In the
  past six months, how often have you given drugs
  to someone so you could have sex with them?
• Respondent asked to check one of seven items
  ranging from never to more than once a day.

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• Sixteen questions used to calculate three
  composite HIV risk scores
• Drug score
• Sex score
• Total score.
• Scores for a single question can range from 0 to
  7,
• with higher values reflecting more instances of
  risk behavior.

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• Of the 487 patients who were randomized, 483
  completed the RAB at study intake and 331
  completed it at both intake and six months. The
  data presented here report RAB data from the 331
  participants who completed it at both assessment
  points.

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Overall Results

• Drug Use Treatment associated with significant
  decreases in cocaine use across all groups with
  the average patient reducing use from 10
  days/month to one day/month at the six-month
  assessment.

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• Average ASI drug use composite score decreased
  from 0.24 at intake where 100 reported cocaine
  use in the last month, to an average of 0.12 at 6
  months, where 50 reported any cocaine use in the
  last month.
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• A significant treatment main effect, with
  patients who received IDC GDC showing less
  cocaine use at 6 months than patients in the
  other three treatment conditions (13).

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HIV Risk Reduction

• Consistent with the crack smoking pattern of most
  patients, almost all HIV risk was in the sexual
  area and treatment participation was associated
  with a substantial reduction in sex risk and in
  total risk (primarily due to the reduction in sex
  risk), as seen in tables 1a and 1b.

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TABLE 1a Change in RAB Sex Risk and Treatment
Condition
Analyses of difference in means controlled by
baseline assessment means followed by the same
letter are not statistically different (pgt0.05)
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TABLE 1b Change in RAB Total Risk and Treatment
Condition
Analyses of difference in means controlled by
baseline assessment means followed by the same
letter are not statistically different (pgt0.05)
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Figure 1
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Figure 3

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Summary

• Treatment is associated with HIV risk reduction
• Shown to reduce HIV infection in case of
  methadone maintenance
• Mechanisms differ according to drug of choice but
  similar in that all associated with less drug use
• For injecting use - fewer injections
• For non-injecting use - less unprotected sex
  less exchanging sex for drugs
• Alcohol dependence associated with increased
  sexual risk, probably due to impaired judgment
  rx probably reduces but few studies