A Novel Combination HIV Prevention Strategy: Post-Exposure Prophylaxis with Contingency Management for Substance Abuse Treatment Among Methamphetamine-Using Men Who Have Sex with Men (original) (raw)
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AIDS Patient Care …, 2012
Methamphetamine use has been associated with HIV transmission among men who have sex with men (MSM). However, providers have been hesitant to utilize post-exposure prophylaxis (PEP) in populations of stimulant users. This single-arm, open label pilot study sought to demonstrate the safety, feasibility, and acceptability of PEP combined with the drug abstinence intervention of contingency management (CM) in methamphetamineusing MSM. HIV-uninfected MSM reporting recent methamphetamine use were recruited to a CM intervention. Those who reported a recent high-risk sexual or injection drug exposure to an HIV-infected or serostatus unknown source were initiated on tenofovir/emtricitabine (Truvada)-based PEP. Participants were followed over 3 months for infectious/biologic, behavioral, and drug use outcomes. Fifty-three participants enrolled in the study; 35 participants (66%) initiated PEP after a high-risk exposure. The median time from exposure to medication administration was 37.8 h (range 12.5-68.0 h). Twenty-five (71.4%) PEP initiators successfully completed the treatment course. Median medication adherence was 96% (IQR 57-100%), and medication was generally well tolerated. Methamphetamine abstinence during CM treatment increased PEP adherence (2% [95% CI + 1-+ 3%]) per clean urine toxicology sample provided), and increased the odds of PEP course completion (OR 1.17, 95% CI 1.04-1.31). One incident of HIV seroconversion was observed in a participant who did not complete PEP treatment, and reported multiple subsequent exposures. Findings demonstrate that PEP, when combined with CM, is safe, feasible, and acceptable as an HIV prevention strategy in methamphetamine-using MSM.
BMC Public Health, 2006
Background In response to increases in methamphatemine-associated sexually transmitted diseases, the San Francisco Department of Public Health implemented a contingency management (CM) field program called the Positive Reinforcement Opportunity Project (PROP). Methods Methamphetamine-using men who have sex with men (MSM) in San Francisco qualified for PROP following expressed interest in the program, provision of an observed urine sample that tested positive for methamphetamine metabolites and self-report of recent methamphetamine use. For 12 weeks, PROP participants provided observed urine samples on Mondays, Wednesdays and Fridays and received vouchers of increasing value for each consecutive sample that tested negative to metabolites of methamphetamine. Vouchers were exchanged for goods and services that promoted a healthy lifestyle. No cash was provided. Primary outcomes included acceptability (number of enrollments/time), impact (clinical response to treatment and cost-effectiveness as cost per patient treated). Results Enrollment in PROP was brisk indicating its acceptability. During the first 10 months of operation, 143 men sought treatment and of these 77.6% were HIV-infected. Of those screened, 111 began CM treatment and averaged 15 (42%) methamphetamine-free urine samples out of a possible 36 samples during the 12-week treatment period; 60% completed 4 weeks of treatment; 48% 8 weeks and 30% 12 weeks. Across all participants, an average of 159(SD=159 (SD = 159(SD=165) in vouchers or 35.1% of the maximum possible ($453) was provided for these participants. The average cost per participant of the 143 treated was $800. Conclusion Clinical responses to CM in PROP were similar to CM delivered in drug treatment programs, supporting the adaptability and effectiveness of CM to non-traditional drug treatment settings. Costs were reasonable and less than or comparable to other methamphetamine outpatient treatment programs. Further expansion of programs like PROP could address the increasing need for acceptable, feasible and cost-effective methamphetamine treatment in this group with exceptionally high rates of HIV-infection.
Public Health Reports
In January 2005, the U.S. Centers for Disease Control and Prevention hosted a national consultation of scientists, public health officials, and community service providers to address growing concerns about the association of methamphetamine use and sexual risk behavior for HIV/STD infection, which is well documented among men who have sex with men. The purpose of the consultation was to review a representation of the current state of the science and practice on the topic in order to reduce the situational link of methamphetamine use and sexual risk. A set of suggestions for future research and programs were developed by the participants. This article provides a summary of content and recommendations from the consultation, and not an exhaustive review of the literature.
Methamphetamine dependence and human immunodeficiency virus risk behavior
Journal of Substance Abuse Treatment, 2008
We examined human immunodeficiency virus (HIV) related risk behaviors among methamphetamine (MA) dependent users. Secondary data analysis was performed on data from a large clinical trial: the Methamphetamine Treatment Project (MTP) (N=784). All MA-dependent participants were enrolled in an outpatient treatment program, receiving either a standard psychosocial intervention (Matrix Model) or Treatment-as-Usual. HIV-related risk behavior, including injection and unsafe sexual practices, was assessed using the AIDS Risk Assessment at baseline, treatment discharge, and 6-, 12, and 36 months following treatment participation. Results indicate that HIV-risk behaviors substantially decreased over time. Treatment factors (retention and completion) and frequency of MA use were both positively associated with increased reduction of HIV risk behaviors. Findings suggest that treatment of MA dependence is promising for reducing behaviors that have been shown to transmit HIV.
Public health reports (Washington, D.C. : 1974)
In January 2005, the U.S. Centers for Disease Control and Prevention hosted a national consultation of scientists, public health officials, and community service providers to address growing concerns about the association of methamphetamine use and sexual risk behavior for HIV/STD infection, which is well documented among men who have sex with men. The purpose of the consultation was to review a representation of the current state of the science and practice on the topic in order to reduce the situational link of methamphetamine use and sexual risk. A set of suggestions for future research and programs were developed by the participants. This article provides a summary of content and recommendations from the consultation, and not an exhaustive review of the literature.
Drug and Alcohol Dependence, 2005
Background: Methamphetamine-dependent gay and bisexual men (GBM) are at high risk for HIV transmission, largely due to drug-associated sexual risk behaviors. This project evaluated the efficacy of four behavioral drug abuse treatments for reducing methamphetamine use and sexual risk behaviors among this population. Methods: In this randomized controlled trial, 162 methamphetamine-dependent (SCID-verified) GBM in Los Angeles County were randomly assigned to one of four treatment conditions for 16 weeks: standard cognitive behavioral therapy (CBT, n = 40), contingency management (CM, n = 42), combined cognitive behavioral therapy and contingency management (CBT + CM, n = 40), and a culturally tailored cognitive behavioral therapy (GCBT, n = 40). Stimulant use was assessed thrice-weekly during treatment using urine drug screens (48 measures). Sexual risk behaviors were monitored monthly (four measures). Follow-up assessments were conducted at 6 (80.0%) and 12 months (79.9%). Results: Statistically significant differences in retention (F(3,158) = 3.78, p < .02), in longest period of consecutive urine samples negative for methamphetamine metabolites (F(3,158) = 11.80, p < .001), and in the Treatment Effectiveness Score were observed by condition during treatment (F(3,158) = 7.35, p < .001) with post hoc analyses showing the CM and CBT + CM conditions to perform better than standard CBT. GEE modeling results showed GCBT significantly reduced unprotected receptive anal intercourse (URAI) during the first 4 weeks of treatment (X 2 = 6.75, p < .01). During treatment between-group differences disappeared at follow-up with overall reductions in outcomes sustained to 1-year. Conclusions: Among high-risk methamphetamine-dependent GBM, drug abuse treatments produced significant reductions in methamphetamine use and sexual risk behaviors. Drug abuse treatments merit consideration as a primary HIV prevention strategy for this population.
Drug abuse treatment as an HIV prevention strategy: a review
Drug and Alcohol Dependence, 2000
We review drug abuse treatment as a means of preventing infection with HIV. Thirty-three studies, with an aggregate of over seventeen thousand subjects, were published in peer-reviewed journals from 1988 -1998. Research on the utility of drug abuse treatment as an HIV prevention strategy has focused primarily on methadone maintenance treatment (MMT) rather than other modalities such as residential or outpatient drug-free treatment. Recent research provides clear evidence that MMT reduces HIV risk behaviors, particularly needle-use, and strong evidence that MMT prevents HIV infection. There is less definitive evidence that MMT reduces needle-sharing and unsafe sexual behavior, or that other treatment modalities prevent HIV infection. Future research should take into account patient self-selection processes and investigate other treatment modalities for heroin and stimulant abuse to determine their effects on HIV risk behaviors and HIV infection.
The open AIDS …, 2010
Background:Methamphetamine is a major contributor to HIV transmission among men who have sex with men (MSM). Recent studies show that up to one-third of methamphetamine-using MSM (MUMSM) inject the drug. We developed a behavioral intervention for MUMSM to decrease unprotected anal intercourse and increase awareness of parenteral HIV transmission risk. This 6-session (3 in-person, 3 by telephone) modular intervention was designed to be tailored to participants’ HIV (+/-) and injection drug user ([IDU] yes/no) status. We present results of formative research used to evaluate the content and to assess feasibility and acceptability of this individual-level HIV risk-reduction intervention.Setting:HIV research clinic in a high MSM and methamphetamine prevalence neighborhood.Project:Avoiding Risks from Methamphetamine-Use (ARM-U) is a brief toolbox intervention that allows counselors to select modules that suit a client’s individual risk profile and intervention needs employing motivational interviewing and cognitive behavioral theory. We evaluated the format and content of the intervention through focus groups and pre-testing of the entire intervention using volunteers from the target population stratified into four groups (HIV+/IDU, HIV-/IDU, HIV+/non-IDU, HIV-/non-IDU). Four individuals in each stratum were recruited to undergo the intervention and complete a satisfaction survey at the end of each in-person session.Results:In total, 25 MUMSM attended one of five focus groups. Participants thought all proposed intervention topics were important and could aid in reducing sexual risk behaviors among MUMSM. However, the neurocognitive effects of methamphetamine were reported to be a barrier to practicing safer sex, condom use negotiation or HIV status disclosure. Fifteen (94%) of 16 participants completed all 6 sessions and the satisfaction survey. On average, participants felt the intervention was useful for MUMSM, made them contemplate and move toward behavior change, and would recommend the program to their peers.Lessons Learned:Based on our formative research, we revised the ARM-U intervention to emphasize pre-planning to avoid combining methamphetamine use and sex or develop strategies to avoid sex risk following methamphetamine use. We also increased emphasis on referrals for care and other requested services. Future efficacy trials are needed to evaluate the intervention’s ability to reduce HIV-associated risk behaviors.
Journal of Urban Health, 2006
Among men who have sex with men (MSM) in Los Angeles County, methamphetamine use is associated with high rates of HIV prevalence and sexual risk behaviors. In four separate samples of MSM who differed in the range of their intensity of methamphetamine use, from levels of recreational use to chronic use to those for MSM seeking drug abuse treatment, the association between methamphetamine use and HIV infection increased as the intensity of use increased. The lowest HIV prevalence rate (23%) was observed among MSM contacted through street outreach who mentioned recent methamphetamine use, followed by MSM who used at least once a month for six months (42%), followed by MSM seeking intensive outpatient treatment (61%). The highest rate (86%) was observed among MSM seeking residential treatment for methamphetamine dependence. The interleaving nature of these epidemics calls for comprehensive strategies that address methamphetamine use and concomitant sexual behaviors that increase risk of HIV transmission in this group already at high risk. These and other data suggest that MSM who infrequently use methamphetamine may respond to lower intensity/lower cost prevention and early intervention programs while those who use the drug at dependence levels may benefit from high intensity treatment to achieve goals of reduced drug use and HIV-risk sexual behaviors.