We recently completed a randomized clinical trial of the efficacy combining contingency management with cognitive behavioral therapy (CBT) for reducing drug use in dually (cocaine- and heroin-) dependent outpatients. A secondary objective of this study is to examine whether sustained HIV-protective behaviors are achieved by adding CBT to voucher-based contingency management. Inner-city methadone-maintained cocaine abusers receiving the CBT intervention were taught: 1) to identify and seek out sources of reinforcement that do not carry risks of HIV; and 2) to develop adaptive problem-focused and emotion-focused coping responses to general and drug-specific stressors that might otherwise trigger HIV-risk behaviors. Analyses are currently underway that will examine the relationship between stress, coping strategies, and HIV risk behaviors in this clinical sample, and determine whether changes in HIV risk behaviors over the course of the study differed for participants who received CBT as part of their study intervention. Another study included preliminary validation of a brief screening instrument for identifying current opiate dependence in HIV-positive inpatients. Patients admitted to an inpatient AIDS ward who indicated past heroin use were administered an 8-item questionnaire assessing aspects of opiate dependence such as tolerance, withdrawal, and compulsive use; these patients provided a urine sample that was tested on-site for the presence of opiates, and they were assesed for symptoms of opioid withdrawal. With the goal of determining the shortest version of the screening instrument with acceptable validity for identifying current opiate dependence (urine positive for opiates and/or symptoms of opiate withdrawal), the sensitivity, specificity, and positive predictive value of various short versions of the questionnaire were calculated. The version of the questionnaire selected consisted of four questions and had sensitivity of 74.1%, specificity 64.4%, and positive predictive value of 71.4%. These results provide a starting point for further development and validation of short screens for opiate dependence in HIV-positive patients.
