Problematic crystal methamphetamine ("meth") use is a prevalent and treatment refractory problem in MSM, and highly associated with HIV sexual risk behavior. This is an application to conduct a pilot randomized controlled trial (RCT) of a behavioral intervention to reduce high risk sex in MSM with meth abuse/dependence who are at risk for HIV acquisition. The intervention incorporates state of the art behavioral risk reduction counseling with behavioral activation therapy (BAT) to help participants re-engage in enjoyable and meaningful life activities not involving drugs. Behavioral activation is an evidence-based treatment for depression that focuses on helping individuals reengage in activities that generate feelings of mastery and pleasure. We chose this strategy for MSM who abuse meth because our formative work revealed that MSM who abuse meth report becoming unable to enjoy activities that they previously enjoyed as a result of ongoing meth use. This lack of enjoyment (anhedonia) in activities that do not involve meth use or sex contributes to the continued use of meth and potentially unsafe sex. The intervention approach was developed and piloted through a NIDA-funded R03, and the proposed pilot RCT is the next logical step in testing this approach. Overview: Building on our prior R03, this is a two-arm pilot RCT of BAT and HIV risk reduction counseling for MSM with meth abuse/dependence. Conceptual Model: The conceptual model focuses on anhedonia (a loss of interest in previously enjoyed activities) as a consequence of continued meth use. Accordingly, for individuals who abuse meth, drug use becomes the central means for (or the only means for) obtaining enjoyment. We hypothesize that an intervention targeting both sexual risk reduction and increasing safe, pleasurable goal-directed activities via BAT will contribute to increased intervention efficacy and, thus, reductions in unprotected sex and meth use. The hypothesized mechanism of action is that behavioral activation will re-engage participants in pleasurable non-drug use activities (e.g., interests or hobbies that were enjoyable before meth use) that will serve as a natural reinforcement for functional behavior, improve depressed mood when not on meth by experiencing increases in pleasure and mastery, and decrease overall distress so that MSM who abuse meth can better benefit from HIV risk reduction counseling. Research Plan Overview: MSM who are HIV-uninfected and meet DSM-IV criteria for a diagnosis of meth (amphetamine) abuse/dependence will be randomized. The two arms include (1) "BAT-RR", behavioral activation therapy and risk reduction counseling which lasts 10 sessions;and (2) the comparison condition, the equivalent risk reduction counseling only for 2 sessions. Participants will be followed for 6 months post-randomization. Main outcomes include sexual risk (primary) and meth use (secondary). Additional secondary outcomes include increases in pleasurable (but safe) activities, increases in HIV information, motivation re: sexual safety, and behavioral skills, decreases in depressive symptoms severity, and decreases in polysubstance use.
Problematic crystal meth use is a prevalent and treatment resistant-problem in men who have sex with men (MSM) domestically, and is highly associated with HIV risk behavior and HIV infection. The present study aims to test a novel treatment for crystal meth use in MSM, incorporating behavioral activation therapy with HIV risk reduction counseling. This approach may be more potent than traditional drug abuse counseling as our preliminary data suggest that MSM who abuse crystal have stopped receiving pleasure from previously enjoyed activities, and behavioral activation therapy involves re-engaging participants in functional and enjoyable activities. If the current RCT pilot is effective at reducing HIV acquisition risk behavior and crystal meth use, in the next grant (NIDA R01) we will work on a combined dissemination and efficacy study- conducting the intervention in drug abuse treatment clinics for MSM, and delivered by drug abuse counselors.
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