HIV RISK REDUCTION AND SUBSTANCE ABUSE TREATMENT

1. 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

5. 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

6. 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 <1978 test positive

7. Six Year HIV Infection Rates by Treatment Status at Time of Enrollment In Study

8. Methadone Levels Study

9. Reasons for HIV Risk Reduction in Methadone Maintenance • Abstinence • If don’t 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

10. 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.

11. 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.

12. 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.

13. Patients recruited by advertisements, from substance abuse treatment programs, referrals from friends or acquaintances, mental health centers, and private mental health providers. 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 >1 day in the past 30 days.

14. 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.

15. Exclusion criteria (cont’d): 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.

16. - 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.

17. Five sites participated: Western Psychiatric Institute and Clinic University of Pennsylvania Brookside Hospital (Nashua, NH) Massachusetts General Hospital McLean Hospital (Belmont, MA).

18. 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.

19. 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.

20. 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

21. 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”.

22. 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.

23. 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.

24. 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.

25. 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. 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).

26. 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.

27. Treatment Condition Baseline Adjusted Mean Month 6 Adjusted Mean IDC (n=77) 5.69 a 3.39 b CT (n=85) 6.63 a 3.87 b,c SE (n=85) 6.17 a 4.71 c GDC (n=84) 6.27 a 3.68 b 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 (p>0.05)

28. Treatment Condition Post-orientation Adjusted Mean Month 6 Adjusted Mean IDC (n=77) 5.90 a 3.40 b CT (n=85) 6.96 a 3.95 b,c SE (n=85 6.20 a 4.83 c GDC (n=84) 6.45 a 3.80 b 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 (p>0.05)

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35. 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