This subproject is one of many research subprojects utilizing the resources provided by a Center grant funded by NIH/NCRR. The subproject and investigator (PI) may have received primary funding from another NIH source, and thus could be represented in other CRISP entries. The institution listed is for the Center, which is not necessarily the institution for the investigator. Recent illicit drug use in HIV patients is associated with non- compliance to prescribed drug regimens. In a pilot study we found that contingent monetary reinforcement of medication compliance, with compliance measured by specialized pill caps which record date and time of bottle openings (MEMS), enhanced compliance. We have received approval for a larger follow-up randomized clinical trial to evaluate an incentive-based intervention in drug users. The intervention differs from that in the prior study in that it is longer in duration, more specifically addresses concomitant drug use, uses non-cash reinforcement and more broadly addresses barriers to adherence by providing MEMS-Feedback Therapy. Reinforcement will be provided in the form of prize 'draws' from a fishbowl. The short-term application of contingencies is designed to 'prime' adherence to prescribed antiretroviral medications, allow secondary reinforcers (e.g. improved well-being) to become apparent, and engage patients in MEMS-Feedback Therapy. One hundred patients with a history of substance use and MEMS-demonstrated non-adherence during a baseline evaluation will be randomly assigned to either: 1) Control intervention: supportive advice around self-reported adherence and advice around the use of cues or 2) Incentives combined with MEMS-Feedback Therapy (IMF group). IMF patients will be reinforced for MEMS-verified adherence on an escalating schedule of the number of allowed 'draws' from the prize fishbowl. IMF patients also will review their MEMS-generated printouts with therapists. Patients will be encouraged to discuss what they thought, how they felt and what they were doing around the times that doses were missed. On-site toxicology testing and substance abuse calendar review will be used to explore temporal and other relationships between MEMS-demonstrated non-adherence and substance use. Reinforcement and training will be provided for 16 weeks. Retention of effects will be studied during an additional 16-week follow-up period when patients will download MEMS data at regularly scheduled clinic visits without receiving additional counseling. The primary outcome measure will be MEMS-measured adherence. Secondary outcome measures will include viral load, the development of genotypic resistance, and measures of service utilization and cost. Important process measures will be whether IMF (cues to remember doses, changes in substance abuse) result in improved adherence.
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