Applying behavioral activation to sustain and enhance the effects of contingency management for reducing stimulant use among individuals with HIV infection

ABSTRACT

There is a high prevalence of stimulant use among HIV-infected individuals, which is associated with suboptimal antiretroviral therapy (ART) adherence, HIV treatment interruptions, detectable HIV viral load, and transmission of HIV via increased sexual risk behavior. Contingency management (CM) is an initially effective treatment for stimulant use. However, the effects of CM are not sustained after the active intervention has ended. One potential contributor to the intractability of existing treatments may be a lack of attention to replacement activities or the role of depressed mood. Behavioral activation (BA) is an evidence-based approach for depression that involves identifying and participating in pleasurable, goal-directed activities. As a potential approach to address the CM rebound effect – informed by our formative qualitative research with the participant population – we conducted an open pilot trial of an intervention combining CM-BA for HIV-infected individuals with stimulant use disorder. Participants completed weekly BA therapy sessions (10–16 sessions) and thrice-weekly toxicology screenings (12 weeks); contingencies were rewarded for negative toxicology tests to support reengagement into positive life activities. Major assessments were conducted at baseline, 3-, and 6-months. Toxicology screening was repeated prior to the 6-month assessment. Eleven participants with stimulant use disorder enrolled; 7 initiated treatment and completed the full intervention. The mean age was 46 (SD = 5.03) and 14% identified as a racial/ethnic minority. Of the completers, the mean change score in self-reported stimulant use within the past 30 days (within-person change; reduction in self-reported stimulant use) was 4.14 days at 3 months and 5.0 days at 6 months [Cohen’s d = 0.89]. The mean change score in weekly toxicology screens (reduction in positive toxicology screens) was .71 at 3 months and 1 at 6 months [Cohen’s d = 1.05]. Exit interviews indicated that the integrated intervention was well received and acceptable. This study provides preliminary evidence that a combined CM-BA intervention for this population was feasible (100% retention at 6-months), acceptable (100% of intervention sessions attended; participants rated the intervention ‘acceptable’ or ‘very acceptable’), and may be an option to augment the potency and sustained impact of CM for this population. Future pilot testing using a randomized controlled design is warranted.

KEYWORDS:

• Stimulants
• contingency management
• behavioral activation
• HIV
• ART

Acknowledgments

We would like to thank Dr. Steven Shoptaw for his guidence with the CM protocol; and Dr. S. Wade Taylor and Mr. Michael Garber for their contributions to the study.

Disclosure statement

No potential conflict of interest was reported by the authors.

Compliance with ethical standards

Ethical approval

All procedures performed involving human participants were in accordance with the ethical standards of the institutional Review Board of The Fenway Institute (Boston, MA) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Funding

This study was funded by a grant from the Harvard University Center For AIDS Research (CFAR), which is funded through the National Institutes of Health (award number: 2P30AI060354-06; multiple PIs: Drs. Mimiaga and Mitty).