A pilot trial of integrated behavioral activation and sexual risk reduction counseling for HIV-uninfected men who have sex with men abusing crystal methamphetamine

An initial randomized controlled trial of a Combined Medication and Behavioral Activation Treatment (CoMBAT) for people with opioid use disorder

INTRODUCTION

Opioid use disorder is a chronic, relapsing disease and a major source of morbidity and mortality in the U.S. Medications for opioid use disorder (MOUD) have been shown to reduce opioid use; however, MOUD maintenance is often suboptimal. Depression is a well-documented risk factor for MOUD treatment disengagement; thus, behavioral interventions to address depression and support ongoing MOUD use in community settings are warranted.

METHODS

We evaluated the feasibility, acceptability, and preliminary efficacy of the CoMBAT (Combined Medication and Behavioral Activation Treatment) intervention via a pilot randomized controlled trial. We hypothesized that the CoMBAT intervention, which uses behavioral activation, motivational interviewing, and problem-solving techniques, would be feasible and acceptable to participants and decrease depression, increase goal-directed activity, improve MOUD care engagement, and reduce opioid use among adults with depressive symptoms who had a missed dose or clinical MOUD visit in the past 30 days. We enrolled 32 participants prescribed methadone or buprenorphine in the community; each received 2 health navigation and substance use counseling sessions (HN_SUC) before being randomized into (a) the 8-session CoMBAT intervention + HN_SUC + treatment as usual or (b) HN_SUC + treatment as usual only. The primary outcomes were intervention feasibility and acceptability. Preliminary efficacy measures included self-reported past-30-day MOUD doses and clinical visits, depressive symptoms, behavioral activation; and opioid-positive urinalysis; each assessed at baseline and 3- and 6-month follow-up visits.

RESULTS

The intervention was feasible (88 % of intervention sessions completed; 100 % retention at 6 months) and acceptable (86 % of intervention participants were satisfied/very satisfied with the intervention at 3-months; and intervention participants had a high level of alliance with their counselor at the mid-point: mean = 5.7 out of 7 [SD = 1.3] and end of their treatment: mean = 5.5 out of 7 [SD = 1.1]. At 6-months, intervention participants reported fewer missed MOUD doses and visits, less depressive symptoms, greater behavioral activation scores, and a lower percentage of opioid-positive toxicology screens relative to the control condition.

CONCLUSION

Findings provide evidence of intervention feasibility and acceptability and demonstrate initial efficacy for ongoing MOUD care engagement, depressive symptom reduction, increased behavioral activity, and reduced opioid use. Future intervention testing in a fully-powered efficacy trial is warranted.

The CHALO! 2.0 mHealth-Based Multilevel Intervention to Promote HIV Testing and Linkage-to-Care Among Men Who Have Sex with Men in Mumbai, India: Protocol for a Randomized Controlled Trial

BACKGROUND

Current programs to engage marginalized populations such as gay and bisexual individuals and other men who have sex with men (MSM) in HIV prevention interventions do not often reach all MSM who may benefit from them. To reduce the global burden of HIV, far-reaching strategies are needed to engage MSM in HIV prevention and treatment. Globally, including low- and middle-income countries, MSM are now widely using internet-based social and mobile technologies (SMTs; eg, dating apps, social media, and WhatsApp [Meta]), which provides an unprecedented opportunity to engage unreached and underserved groups, such as MSM for HIV prevention and care.

OBJECTIVE

This study aimed to assess the effectiveness of a multilevel mobile health (mHealth)-based intervention to improve HIV testing uptake and status neutral linkage-to-care among sexually active MSM reached through internet-based platforms in Mumbai, India.

METHODS

In this randomized controlled trial, we will determine whether CHALO! 2.0 (a theory-based multilevel intervention delivered in part through WhatsApp) results in increased HIV testing and linkage-to-care (prevention or treatment). This study is being conducted among 1000 sexually active MSM who are unaware of their HIV status (never tested or tested >6 months ago) and are recruited through SMTs in Mumbai, India. We will conduct a 12-week, 3-arm randomized trial comparing CHALO! 2.0 to 2 control conditions-an attention-matched SMT-based control (also including a digital coupon for free HIV testing) and a digital coupon-only control. The primary outcomes will be HIV testing and status neutral linkage-to-care by 6 months post enrollment. Participants will be followed up for a total of 18 months to evaluate the long-term impact.

RESULTS

The study was funded in 2020, with recruitment having started in April 2022 due to delays from the COVID-19 pandemic. Baseline survey data collection began in April 2022, with follow-up surveys starting in July 2022. As of April 2022, we enrolled 1004 participants in the study. The completion of follow-up data collection is expected in January 2025, with results to be published thereafter.

CONCLUSIONS

While global health agencies have called for internet-based interventions to engage populations vulnerable to HIV who are not being reached, few proven effective and scalable models exist and none is in India, which has one of the world's largest HIV epidemics. This study will address this gap by testing a multicomponent mHealth intervention to reach and engage MSM at high priority for HIV interventions and link them to HIV testing and prevention or treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04814654; https://clinicaltrials.gov/study/NCT04814654. Clinical Trial Registry of India CTRI/2021/03/032280.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59873.

A Transdiagnostic Treatment to Improve Biomedical and Syndemic Outcomes in People Living With HIV

People living with HIV (PLWH) experience a range of co-occurring psychosocial stressors, mental health symptoms, and structural barriers (e.g., "syndemics") that can impair their ability to adhere to medical recommendations for treatment. This has consequences for their health and the health of others as nonadherence increases the likelihood of unsuppressed HIV viral load, and therefore the ability to transmit HIV to others. Transdiagnostic treatment, or treatment not focused on a single mental health condition, can efficiently address a range of mental health problems by skills training to reduce symptoms. Additionally, cognitive behavioral and problem-solving approaches can be used to address larger, structural factors by helping individuals navigate systemic challenges using evidence-based skills. This article describes the development of a transdiagnostic treatment for PLWH and illustrates the application of the treatment through case examples. This treatment might be appropriate for integration into an HIV clinic or within an outpatient setting when working with a patient who is experiencing syndemic conditions and living with HIV.

Minority Stress, Psychological Distress, Sexual Compulsivity, and Avoidance-Based Motivations Associated with Methamphetamine Use Among Sexual Minority Men Living with HIV: Examining Direct and Indirect Associations Using Cross-Sectional Structural Equation Modeling

OBJECTIVE

Sexual minority men (SMM) living with HIV report significantly greater methamphetamine use compared with heterosexual and HIV-negative peers. Greater use may be related to stressors (e.g., HIV-related stigma) faced by SMM living with HIV and subsequent psychological and behavioral sequelae. We tested an integrated theoretical model comprised of pathways between stigma, discrimination, childhood sexual abuse, psychological distress, sexual compulsivity, and cognitive escape in predicting methamphetamine use among SMM living with HIV.

METHODS

Among 423 SMM living with HIV, we tested a structural equation model examining factors hypothesized to be directly and indirectly associated with methamphetamine use. Analyses were adjusted for demographic covariates and sampling bias.

RESULTS

The model showed good fit (CFI = 0.96, RMSEA = 0.01). Heterosexist discrimination was associated with psychological distress (β = 0.39, p < 0.001) and psychological distress was associated with sexual compulsivity (β = 0.33, p < 0.001). Sexual compulsivity was associated with cognitive escape (β = 0.31, p < 0.001), which was associated with methamphetamine use (β = 0.51, p < 0.001). Psychological distress was associated with methamphetamine use via serial indirect effects of sexual compulsivity and cognitive escape (β = 0.05, p < 0.05).

CONCLUSIONS

Heterosexist discrimination contributed to psychological distress among SMM living with HIV. Psychological distress is linked to methamphetamine use via sexual compulsivity and cognitive avoidance. Interventions seeking to reduce the likelihood that SMM living with HIV use methamphetamine should include coping strategies specific to heterosexism and related psychological distress.

Behavioral therapies targeting reward mechanisms in substance use disorders

Behavioral therapies are considered best practices in the treatment of substance use disorders (SUD) and used as first-line approaches for SUDs without FDA-approved pharmacotherapies. Decades of research on the neuroscience of drug reward and addiction have informed the development of current leading behavioral therapies that, while differing in focus and technique, have in common the overarching goal of shifting reward responding away from drug and toward natural non-drug rewards. This review begins by describing key neurobiological processes of reward in addiction, followed by a description of how various behavioral therapies address specific reward processes. Based on this review, a conceptual 'map' is crafted to pinpoint gaps and areas of overlap, serving as a guide for selecting and integrating behavioral therapies.

Association of Partnership-Level Methamphetamine Use on Inconsistent PrEP Care Engagement Among GBMSM in Los Angeles County

There are limited quantitative studies describing the association between meth use in the context of male-male sexual partnerships and PrEP care engagement. We assessed the longitudinal relationship between individual and partnership level meth use with inconsistent PrEP engagement among young gay, bisexual and other men who have sex with men (GBMSM) in Los Angeles. The primary exposure was meth use at the partnership level with a ternary variable (neither partner nor participant used meth, either used meth, or both used meth). Generalized estimating equations were used to assess odds of inconsistent PrEP engagement at different levels of partner-participant meth use, adjusting for age at visit, number of recent male partners and partner intimacy. Among inconsistent PrEP engagement, 61% (n = 84, vs. 79.5%, n = 346 continuous) reported that neither they nor their partner used meth, 22% (n = 31, vs. 18%, n = 56) reported that either partner or participant used meth and 17% (n = 24, vs. 8%, n = 33) reported that both partner and participant used meth (P < 0.01). There were increased odds of inconsistent PrEP engagement when both partner and participant reported meth use (aOR: 3.82; 95%CI: 1.83-7.99) and when either partner or participant reported meth use (aOR: 2.46; 95%CI: 1.28-4.75). Meth use plays an important role in consistent PrEP engagement among GBMSM in mSTUDY. PrEP users who use meth with partners may benefit from integrated interventions addressing both meth use and PrEP engagement.

Prevalence of methamphetamine use among gay, bisexual and other men who have sex with men: A systematic review and meta-analysis

BACKGROUND

International efforts have reduced the availability of methamphetamine precursors, but its distribution and use continue to rise. Methamphetamine use can lead to short- and long-term adverse effects, including addiction, physical and psychosocial health problems, socioeconomic troubles, incarceration, overdose, and death. Gay, bisexual, and other men who have sex with men (MSM) have been shown to have an elevated prevalence of methamphetamine use.

METHODS

We conducted a systematic review and meta-analysis to estimate the prevalence of methamphetamine use among MSM. We searched electronic databases, such as PubMed, for peer-reviewed literature published between 2011 and 2022. Data on methamphetamine use were extracted, including study features, location, study design, sampling method, recruitment period, specific MSM subgroups, prevalence period, and demographics. Employing a random-effects model, we computed the pooled prevalence of methamphetamine use among MSM across two prevalence periods: recent use (i.e., one month, three months, six months, one year) and lifetime use.

RESULTS

The systematic review included 56 studies with a total of 25,953 MSM who use methamphetamine. Most studies were conducted in Europe, with the highest prevalence reported in the United Kingdom. The studies primarily used cross-sectional or cohort study designs with convenience sampling. The pooled prevalence rates across recent use (i.e., past month, past three months, past six months, and past year) was 15% (95% CI [11-19%]). Additionally, we pooled lifetime use, which was 23% (95% CI [9-38%]). High heterogeneity (I2 > 99%) was observed, indicating significant variation.

CONCLUSION

This systematic review and meta-analysis provide a pooled prevalence of methamphetamine use among MSM. The analysis accounts for study design, prevalence period, specific MSM subgroups, and geographical areas to estimate methamphetamine use in diverse settings and populations. The review highlights the need for targeted interventions and harm reduction strategies focused on prevention, education, healthcare access, and stakeholder collaboration to address the multifaceted challenges of methamphetamine use among MSM.

Attitudes of Gay, Bisexual, and Other Men Who Have Sex with Men (GBM) toward Their Use of Amphetamine-Type Stimulants and Relation to Reducing Use in Three Canadian Cities

BACKGROUND

We explored attitudes of gay, bisexual, and other men who have sex with men (GBM) toward their amphetamine-use and associations with reduced use over time.

METHODS

We recruited sexually-active GBM aged 16+ years in Montreal, Toronto, and Vancouver, Canada, from 02-2017 to 08-2019, with follow-up visits every 6-12 months until November 2020. Among participants who reported past-six-month (P6M) amphetamine-use at enrollment, we used logistic regression to identify demographic, psychological, social, mental health, other substance-use, and behavioral factors associated with reporting needing help reducing their substance-use. We used mixed-effects logistic regression to model reduced P6M amphetamine-use with perceived problematic-use as our primary explanatory variable.

RESULTS

We enrolled 2,449 GBM across sites. 15.5-24.7% reported P6M amphetamine-use at enrollment and 82.6 - 85.7% reported needing no help or only a little help in reducing their substance use. Reporting needing a lot/of help or completely needing help in reducing substance-use was associated with group sex participation (AOR = 2.35, 95%CI:1.25-4.44), greater anxiety symptomatology (AOR = 2.11, 95%CI:1.16-3.83), greater financial strain (AOR = 1.35, 95%CI:1.21-1.50), and greater Escape Motive scores (AOR = 1.07, 95%CI:1.03-1.10). Reductions in P6M amphetamine-use were less likely among GBM who perceived their amphetamine-use as problematic (AOR = 0.17 95% CI 0.10 - 0.29).

CONCLUSIONS

Most amphetamine-using GBM did not feel they needed help reducing their substance use, and many reported reduced amphetamine-use at subsequent visits. Those who perceived their use as problematic were less likely to reduce their use. Further interventions to assist GBM in reducing their use are needed to assist those who perceive their use as problematic.

"You rise up and then you start pulling people up with you": Patient experiences with a peer-delivered behavioral activation intervention to support methadone treatment

BACKGROUND

Although medications for opioid use disorder (MOUD) are efficacious treatments for opioid use disorder, retention remains low. Peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, may be particularly well-suited to support patients receiving MOUD. While PRSs are rarely trained in evidence-based behavioral interventions other than motivational interviewing, preliminary evidence suggests that peers can deliver brief behavioral interventions, such as behavioral activation, with efficacy and fidelity. This qualitative study sought to explore patient perspectives on receiving an adapted PRS-delivered behavioral activation intervention (Peer Activate) to support patients receiving methadone treatment.

METHODS

The sample (N = 26) included patients recently starting or demonstrating challenges with adherence at a community-based methadone treatment program who received the Peer Activate intervention in a pilot trial. Participants were invited to participate in in-depth, semi-structured interviews at study completion or discontinuation, assessing perceived acceptability and feasibility of Peer Activate, and stigma-related barriers. Interview transcripts were coded using codebook/template thematic analysis.

RESULTS

Analysis revealed the importance of two areas to promote intervention acceptability: 1) connection with intervention content and skill building, and 2) valued PRS-specific qualities. Intervention flexibility was found to promote feasibility of the intervention in the context of chaotic and challenging life circumstances. Additionally, participants described stigma towards substance use and methadone treatment as potential barriers to engaging in methadone treatment.

CONCLUSION

Results support the acceptability and feasibility to patients of this PRS-delivered behavioral activation intervention in the context of outpatient MOUD treatment among a low-income, majority racially minoritized patient population. Future intervention adaptation and implementation should focus on incorporating content related to relationships and interpersonal skills; balancing behavioral intervention content with system navigation support; maintaining flexibility; and further investigation of the impact of individual PRS attributes, including shared lived experiences, on intervention acceptability and shifts in stigma.

Peer Activate: A Feasibility Trial of a Peer-Delivered Intervention to Decrease Disparities in Substance Use, Depression, and Linkage to Substance Use Treatment

Although effective evidence-based interventions (EBIs) exist, racial/ethnic minority individuals with lower income are less likely to have access to these interventions and may experience greater stigma in the health care system, resulting in disproportionate rates of morbidity and mortality. Peer recovery specialists (PRSs) may be uniquely suited to address barriers faced by those from impoverished areas; however, peers have not traditionally been trained in implementing EBIs. The current open-label trial (N = 8) was performed to evaluate implementation and preliminary effectiveness of an adapted EBI supporting recovery, linkage to treatment, and reduced depression. Results suggest the intervention was feasible, acceptable, and appropriate for linking individuals from a community setting to substance use treatment and could be delivered with fidelity by a peer interventionist. Participants who completed the intervention demonstrated clinically reliable decreases in substance use and depressive symptoms. Findings provide initial support for PRS dissemination of EBIs to increase linkage to care and support recovery in traditionally underserved populations. [Journal of Psychosocial Nursing and Mental Health Services, 61(11), 23-31.].

Peer recovery specialist-delivered, behavioral activation intervention to improve retention in methadone treatment: Results from an open-label, Type 1 hybrid effectiveness-implementation pilot trial

BACKGROUND

Despite the efficacy of methadone to treat opioid use disorder (OUD), retention is an urgent priority, particularly among low-income, minoritized populations. Peer recovery specialists are well-positioned to engage vulnerable patients, particularly when trained in an evidence-based intervention to promote retention. This hybrid effectiveness-implementation pilot trial aimed to demonstrate the proof of concept of a peer recovery specialist-delivered behavioral activation and problem solving-based approach (Peer Activate) to improve methadone retention.

METHODS

Implementation outcomes included feasibility, acceptability, and fidelity. Feasibility and acceptability were defined by the percentage of participants who initiated the intervention (≥75%) and completed ≥75% of core sessions, respectively. Fidelity was assessed via independent rating of a randomly selected 20% of sessions. The primary effectiveness outcome was methadone retention at three-months post-intervention vs. a comparison cohort initiating methadone during the same time period. Secondary outcomes included methadone adherence, substance use frequency, and substance use-related problems.

RESULTS

Benchmarks for feasibility and acceptability were surpassed: 86.5% (32/37) initiated the intervention, and 81.3% of participants who initiated attended ≥75% of core sessions. The mean independent rater fidelity score was 87.9%, indicating high peer fidelity. For effectiveness outcomes, 88.6% of participants in Peer Activate were retained in methadone treatment at three-months post-intervention-28.9% higher than individuals initiating methadone treatment alone in the same time period [χ2(1) = 10.10, p = 0.001]. Among Peer Activate participants, urine-verified methadone adherence reached 97% at post-intervention, and there was a significant reduction in substance use frequency from 48% of past two-week days used at baseline to 31.9% at post-intervention [t(25) = 1.82, p = .041]. Among participants who completed the core Peer Activate sessions (n = 26), there was a significant reduction in substance use-related problems [t(21) = 1.84, p = 0.040].

CONCLUSION

Given the rapid scale-up of peer recovery specialist programs nationwide and the urgent need to promote methadone retention, these results, although preliminary, have important potential clinical significance. The next steps are to conduct a Type 1 hybrid effectiveness-implementation randomized trial with a larger sample size and longer-term follow-up to further establish the implementation and effectiveness of the Peer Activate approach.

A scoping review of alcohol, tobacco, and other drug use treatment interventions for sexual and gender minority populations

BACKGROUND

Alcohol, tobacco, and other drug use are among the most prevalent and important health disparities affecting sexual and gender minority (SGM; e.g., lesbian, gay, bisexual, transgender) populations. Although numerous government agencies and health experts have called for substance use intervention studies to address these disparities, such studies continue to be relatively rare.

METHOD

We conducted a scoping review of prevention and drug treatment intervention studies for alcohol, tobacco, and other drug use that were conducted with SGM adults. We searched three databases to identify pertinent English-language, peer-reviewed articles published between 1985 and 2019.

RESULTS

Our search yielded 71 articles. The majority focused on sexual minority men and studied individual or group psychotherapies for alcohol, tobacco, or methamphetamine use.

CONCLUSION

Our findings highlight the need for intervention research focused on sexual minority women and gender minority individuals and on cannabis and opioid use. There is also a need for more research that evaluates dyadic, population-level, and medication interventions.

Act Healthy: A Randomized Clinical Trial Evaluating a Behavioral Activation Intervention to Address Substance Use and Medication Adherence Among Low-Income, Black/African American Individuals Living with HIV/AIDS

There is a need for parsimonious behavioral interventions to support HIV and substance use treatment outcomes for low-income, Black/African American individuals living with HIV. This randomized clinical trial (N = 61) evaluated Act Healthy (AH), an integrated behavioral intervention to reduce substance use and improve medication adherence, compared to supportive counseling (SC) plus Life-Steps medication adherence counseling on substance use, craving, adherence-related outcomes, and depression over one year. Participants in AH had significantly steeper decreases in cravings compared to SC, but no significant differences in substance use. Across both groups, there was a significant increase in probability of being on antiretroviral therapy (ART) (86% on ART at 12 months vs. 56% at baseline), and a significant decrease in medication nonadherence. Findings provide preliminary support for an intervention to reduce cravings and strategies to improve ART use in a hard-to-reach, vulnerable population at high risk for poor treatment outcomes and ongoing HIV transmission. TRIAL REGISTRATION: ClinicalTrials.gov trial registration number: identifier: NCT01351454. Retrospectively registered on May 10, 2011.

The Past, Present, and Future of PrEP implementation Among People Who Use Drugs

PURPOSE OF REVIEW

Recent HIV outbreaks among people who use drugs (PWUD) necessitate additional HIV prevention tools. Pre-exposure prophylaxis (PrEP) is highly efficacious yet uptake among PWUD remains exceedingly low. To address multilevel, complex barriers to PrEP use among PWUD, a range of intervention strategies are needed.

RECENT FINDINGS

The literature on interventions to optimize PrEP use among PWUD is nascent, comprising small pilots and demonstration projects in early phases of intervention development. Initial studies suggest that structural, healthcare, interpersonal, and individual-level interventions can improve PrEP use for PWUD, and a number of efficacy trials are underway. Future studies are needed to optimize the use of new PrEP modalities (e.g., injectable PrEP), simultaneously target multilevel challenges to PrEP use, and evaluate the integration of PrEP into other service settings and substance use treatment modalities.

Psychosocial Interventions for Amphetamine Type Stimulant Use Disorder: An Overview of Systematic Reviews

Introduction: Amphetamine-type stimulants (ATS) use is a global concern due to increased usage and the harm to physical, mental, and social well-being. The objective of this overview of systematic reviews is to summarise trial results of psychosocial interventions and describe their efficacy and safety. Methods: We searched seven bibliographic databases to November 2020 for systematic reviews examining ATS misuse treatment by psychosocial interventions. Given the apparent incompleteness of the included reviews, we undertook a supplemental meta-analysis of all eligible primary studies. Results: We included 11 systematic reviews of moderate to high quality and 39 primary studies which assessed the outcomes of psychosocial interventions on people who use ATS. The key findings include: (1) There were conflicting results about the effectiveness of psychosocial interventions among reviews, which may confuse decision-makers in selecting treatment. (2) In the supplemental meta-analysis, relative to usual care (only counselling or self-help materials), membership of a psychological intervention group was associated with an important reduction in drug usage [risk ratio (RR) 0.80, 95% CI: 0.75 to 0.85]. Patients in psychological interventions used injectables substantially less [odds ratio (OR) 0.35, 95% CI: 0.24 to 0.49]. The risk of unsafe sex in the psychosocial intervention group was lower than in the control group (RR 0.49, 95% CI: 0.34 to 0.71). The combination of therapies reduced 1.51 day using drugs in the preceding 30 days (95% CI: -2.36 to -0.67) compared to cognitive behavioural therapy intervention alone. (3) Compared to usual care, cognitive behavioural therapy was less likely to be retained at follow-up (RR 0.89, 95% CI: 0.82 to 0.97; high-quality evidence). However, the additional of contingency management strategy can make an important improvement upon retention (RR 1.42, 95%CI: 1.25 to 1.62). Authors' Conclusions: Integrated models are more effective than a single-treatment strategy. Comprehensive and sustained psychosocial interventions can help to reduce use of ATS and other drugs, risk behaviours and mental disorders, and significantly improve treatment adherence.

Intervening for HIV prevention and mental health: a review of global literature

INTRODUCTION

Numerous effective HIV prevention options exist, including behaviour change interventions, condom promotion and biomedical interventions, like voluntary medical male circumcision and pre-exposure prophylaxis. However, populations at risk of HIV also face overlapping vulnerabilities to common mental disorders and severe mental illness. Mental health status can affect engagement in HIV risk behaviours and HIV prevention programmes. We conducted a narrative review of the literature on HIV prevention among key populations and other groups vulnerable to HIV infection to understand the relationship between mental health conditions and HIV prevention outcomes and summarize existing evidence on integrated approaches to HIV prevention and mental healthcare.

METHODS

We searched five databases for studies published from January 2015 to August 2020, focused on HIV prevention and mental health conditions among key populations and individuals with serious mental illness. Studies were included if they evaluated an HIV prevention intervention or assessed correlates of HIV risk reduction and included assessment of mental health conditions or a mental health intervention.

RESULTS AND DISCUSSION

We identified 50 studies meeting our inclusion criteria, of which 26 were randomized controlled trials or other experimental designs of an HIV prevention intervention with or without a mental health component. Behaviour change interventions were the most common HIV prevention approach. A majority of studies recruited men who have sex with men and adolescents. Two studies provided distinct approaches to integrated HIV prevention and mental health service delivery. Overall, a majority of included studies showed that symptoms of mental disorder or distress are associated with HIV prevention outcomes (e.g. increased risky sexual behaviour, poor engagement in HIV prevention behaviours). In addition, several studies conducted among groups at high risk of poor mental health found that integrating a mental health component into a behaviour change intervention or linking mental health services to combination prevention activities significantly reduced risk behaviour and mental distress and improved access to mental healthcare.

CONCLUSIONS

Evidence suggests that mental health conditions are associated with poorer HIV prevention outcomes, and tailored integrated approaches are urgently needed to address overlapping vulnerabilities among key populations and other individuals at risk.

Strengthening resilience to reduce HIV risk in Indian MSM: a multicity, randomised, clinical efficacy trial

BACKGROUND

Men who have sex with men (MSM) in India are extremely marginalised and stigmatised, and therefore experience immense psychosocial stress. As current HIV prevention interventions in India do not address mental health or resilience to these stressors, we aimed to evaluate a resilience-based psychosocial intervention in the context of HIV and sexually transmitted infection (STI) prevention.

METHODS

We did a multicity, randomised, clinical efficacy trial in Chennai (governmental tuberculosis research institute) and Mumbai (non-governmental organisation for MSM), India. Inclusion criteria were MSM, aged 18 years or older, who were at risk of HIV acquisition or transmission, defined as having any of the following in the 4 months before screening: anal sex with four or more male partners (protected or unprotected), diagnosis of an STI, history of transactional sex activity, or condomless anal sex with a man who was of unknown HIV status or serodiscordant. Participants were required to speak English, Tamil (in Chennai), or Hindi (in Mumbai) fluently. Eligible individuals were randomly assigned (1:1) to either a resilience-based psychosocial HIV prevention intervention, consisting of group (four sessions) and individual (six sessions) counselling alongside HIV and STI voluntary counselling and testing, or a standard-of-care control comprising voluntary counselling and testing alone. The primary outcomes were number of condomless anal sex acts with male partners during the past month (at baseline and 4 months, 8 months, and 12 months after randomisation), and incident bacterial STIs (at 12 months after randomisation). Resilience-related mediators included self-esteem, self-acceptance, and depression. Recruitment is now closed. This trial is registered with ClinicalTrials.gov, NCT02556294.

FINDINGS

Between Sept 4, 2015, and June 28, 2018, we enrolled 608 participants; 305 (50%) were assigned to the psychosocial intervention condition and 303 (50%) were assigned to the control condition. 510 (84%) of 608 men completed an assessment at 4 months after randomisation, 483 (79%) at 8 months, and 515 (85%) at 12 months. 512 (99%) of 515 men had STI data from the 12-month assessment. The intervention condition had a 56% larger reduction in condomless anal sex acts (95% CI 35-71; p<0·0001) from baseline to 4-month follow-up, 72% larger reduction (56-82; p<0·0001) from baseline to 8-month follow-up, and 72% larger reduction (53-83; p<0·0001) from baseline to 12-month follow-up, compared with the standard-of-care control condition (condition by time interaction; χ2=40·29, 3 df; p<0·0001). Improvements in self-esteem and depressive symptoms both mediated 9% of the intervention effect on condomless anal sex acts. Bacterial STI incidence did not differ between study conditions at 12-month follow-up.

INTERPRETATION

A resilience-based psychosocial intervention for MSM at risk of HIV acquisition or transmission in India was efficacious in reducing condomless anal sex acts, with evidence for mediation effects in two key target resilience variables. HIV prevention programmes for MSM in India should address mental health resilience to augment reductions in the risk of sexually transmitted HIV.

FUNDING

National Institute of Mental Health.

Addressing Syndemics and Self-care in Individuals with Uncontrolled HIV: An Open Trial of a Transdiagnostic Treatment

Interventions addressing syndemics and ART adherence are needed for individuals with uncontrolled HIV and psychosocial problems. Twenty-seven participants with detectable HIV plasma viral load (PVL) or recent STI participated in an open trial of transdiagnostic adherence counseling and cognitive behavioral therapy. Outcomes were collected at baseline, 4-, and 8-months. Log PVL improved from baseline to 4-month (γ = - 1.13, 95% CI - 1.72, - 0.55, p < 0.001) and 8-month (γ = - 0.93, 95% CI - 1.57, - 0.30, p = 0.006), with more participants suppressed at 4- (χ2(1) = 9.09, p = 0.001) and 8-month (χ2(1) = 5.14, p = 0.016). Self-reported adherence improved across major assessments (γ = 0.87, 95% CI 0.28, 1.46, p = .005); Wisepill adherence did not. Negative affect declined during treatment (γ = - 0.28, 95% CI - 0.40, - 0.16, p < 0.001), with improvement at 4- (γ = - 4.34, 95% CI - 6.99, - 1.69, p = 0.002) but not 8-month. Positive affect trended positively during treatment and from baseline to 4-month, with significant 8-month improvement (γ = 3.84, 95% CI 0.33, 7.44, p = 0.04). Depressive symptoms did not change. In a complicated sample of participants selected for uncontrolled HIV, the intervention yielded improved PVL and self-reported adherence. Efforts to end HIV should improve upon strategies such as these, addressing syndemics. Registration: clinicaltrial.gov: NCT02696681.

A Systematic Review and Meta-Analysis of Combination Behavioral Interventions Co-Targeting Psychosocial Syndemics and HIV-Related Health Behaviors for Sexual Minority Men

In the U.S., sexual minority men (SMM) are disproportionately affected by HIV. Interventions are needed to increase HIV prevention and treatment behaviors, especially among syndemically exposed SMM. In recent years, researchers have created and tested combination behavioral interventions co-targeting syndemics and HIV-related health behaviors. We evaluated that literature via systematic review and meta-analysis, identifying 44 trials targeting mental health symptoms, alcohol use, and drug use, as well as sexual risk behavior, antiretroviral adherence, and healthcare engagement. For the randomized controlled trials, we computed between-group, pre-post effect sizes and tested them via random-effects models. Results supported the efficacy of combined interventions with significant, small, positive effects for improving mental health and reducing substance use (d = .20, CIs: 0.12, .29), and reducing sexual risk behavior and improving antiretroviral adherence (d = .16, CIs: .03, .30). Stratification analyses indicate that longer (9+ sessions) and individual (vs. group) interventions resulted in stronger effects on syndemic but not health behavior outcomes. Intervention developers should attend to intervention intensity and format. More evidence is needed about the importance of additional factors, such as novel intervention targets and cultural tailoring, as well as broadening the focus to multi-level interventions to address both interpersonal and structural mechanisms of change.

How Intersectional Are Mental Health Interventions for Sexual Minority People? A Systematic Review

Purpose: Complex and widespread stigma exposes sexual minority people to disproportionate risks for adverse mental health. Intersectionality theory calls for consideration of the unique experiences of living with multiple forms of inequality. Yet, concerns remain regarding the extent to which intersectionality theory has been integrated into mental health interventions for sexual minority populations. This systematic review aims to assess the degree to which available mental health interventions account for intersecting forms of marginalization and to identify methods that facilitate the application of intersectionality. Methods: A search for peer-reviewed English language journal articles was conducted using PsycINFO and PubMed to locate reports of mental health interventions for sexual minority groups. A coding framework was designed to evaluate how interventions incorporated intersectionality theory. Results: Of 1877 potentially eligible articles, forty-three were included in the analysis. They were each classified as low, medium, or high with regard to intersectionality. Thirteen (30.2%) were rated as low on intersectionality for only recruiting a homogeneous group of participants in the interventions; 23 (53.4%) were classified as medium for including additional identities in recruitment without responding to possible intersectional disadvantages; 7 (16.3%) were rated as high with adequate consideration of the complex effects of intersecting positions. In addition, the review identified community-based participatory research as a common and instrumental method to ensure intersectionality. Conclusions: This review highlights the limitations of interventions for sexual minority people in addressing intersectionality. Guidelines are needed for clinical practice and evaluation to adequately incorporate intersectionality theory.

Engaging, retaining, and providing transdiagnostic integrated cognitive-behavioral therapy and motivational interviewing for underserved people with HIV

People with HIV experience elevated levels of co-occurring psychosocial concerns, which can interfere with HIV-related self-care behaviors, such as medication adherence. We recently developed transdiagnostic, integrated cognitive-behavioral therapy and motivational interviewing psychotherapy to address interrelated psychosocial problems (syndemics) that can interfere with medication adherence and self-care among people with uncontrolled HIV (i.e., a detectable viral load). Through completion of a field trial that included development, clinical supervision, treatment, and administrative coordination of this project, we identified recommendations for engaging, retaining, and delivering transdiagnostic cognitive-behavioral therapy/motivational interviewing to individuals with HIV and experiencing psychosocial and structural barriers to mental and physical health. We describe these recommendations, which include (a) building the relationship; (b) addressing HIV in the context of syndemics; (c) attending to the impact of stigma on health; (d) being flexible in delivering the treatment; (e) managing emergent crises with relevant skill material; (f) tailoring the treatment to education, language, and sociocultural context; (g) implementing problem-solving skills for structural barriers; (h) scheduling flexibly and following up; (i) colocating mental health services and coordinating among providers; and (j) providing a comfortable and affirming physical space. In addition to describing these recommendations, we provide clinical examples and highlight empirical research to illustrate and support using these recommendations. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

"Too much boredom isn't a good thing": Adapting behavioral activation for substance use in a resource-limited South African HIV care setting

South Africa has the largest HIV/AIDS burden globally. In South Africa, substance use is prevalent and interferes with HIV treatment adherence and viral suppression, and yet it is not routinely treated in HIV care. More research is needed to adapt scalable, evidence-based therapies for substance use for integration into HIV care in South Africa. Behavioral activation (BA), originally developed as an efficacious therapy for depression, has been feasibly used to treat depression in low- and middle-income countries and substance use in high-income settings. Yet, to date, there is limited research on using BA for substance use in low- and middle-income countries. Guided by the ADAPT-ITT framework, this study sought to adapt BA therapy for substance use in HIV care in South Africa. We conducted semistructured individual interviews among patients (n = 19) with moderate/severe substance use and detectable viral load, and HIV care providers and substance use treatment therapists (n = 11) across roles and disciplines at 2 clinic sites in a peri-urban area of Cape Town. We assessed patient and provider/therapist views on the appropriateness of the BA therapy model and sought feedback on isiXhosa-translated BA therapy components. Participants identified the central role of boredom in contributing to substance use and saw the BA therapy model as highly appropriate. Participants identified church and religious practices, sports, and yard/housework as relevant substance-free activities. These findings will inform adaptations to BA therapy for substance use and HIV medication adherence in this setting. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Adapting a peer recovery coach-delivered behavioral activation intervention for problematic substance use in a medically underserved community in Baltimore City

Low-income, racial/ethnic minority groups have disproportionately high rates of problematic substance use yet face barriers in accessing evidence-based interventions (EBIs). Peer recovery coaches (PRCs), individuals with lived experience with problematic substance use, may provide an effective approach to reaching these individuals. Traditionally PRCs have focused on bridging to other types of care rather than delivering EBIs themselves. The aim of this study was to assess perceptions of the appropriateness of a PRC-delivered adapted behavioral activation (BA) intervention to reduce problematic substance use for individuals not engaged in care. This study was conducted at a community resource center in Baltimore, Maryland serving low-income and homeless clients who have high rates of problematic substance use yet also face barriers to accessing care. Guided by the ADAPT-ITT framework, we conducted semi-structured key informant interviews with clients (n = 30) with past or present problematic substance use, and a focus group with community providers, including staff at the community resource center (n = 5) and PRCs (n = 6) from the community. Thirty percent (n = 9) of clients interviewed reported past problematic substance use and 70% (n = 21) met criteria for current use, most commonly cocaine and opioids. Clients, center staff, and PRCs shared that PRC-delivered BA could be acceptable and appropriate with suggested adaptations, including adding peer-delivered case-management and linkage to care alongside BA, and tailoring BA to include activities that are accessible and feasible in the community. These findings will inform the adaptation of PRC-delivered BA to address problematic substance use in this setting.

Factors Associated with Cessation or Reduction of Methamphetamine Use among Gay, Bisexual, and Other Men Who Have Sex with Men (gbMSM) in Vancouver Canada

Background: Methamphetamine (MA) use among gay, bisexual, and other men who have sex with men (gbMSM) is a pervasive issue, associated with detrimental health outcomes. We identified factors associated with discontinuation or reduction in MA among a subset of gbMSM reporting frequent (at least weekly) use, with a specific focus on symptoms of anxiety and depression. Methods: We recruited sexually-active gbMSM aged ≥16 years in Vancouver, Canada into a prospective-cohort study using respondent-driven sampling. Participants completed study visits once every six months. We used generalized linear mixed models to identify factors associated with reductions in MA use following a visit where participants previously reported using MA at least weekly. Results: Of 584 cohort participants with at least one follow-up visit, 67 (11.5%) reported frequent MA use at baseline or in follow-up visits. Of these, 46 (68.7%) had at least one subsequent study visit where they transitioned to less frequent (monthly or less) or no MA use. In multivariable models, reduced MA use was less likely for those who spent >50% of social time with other gbMSM (aRR = 0.49, 95%CI:0.28-0.85), gave or received drugs in exchange for sex (aRR = 0.34, 95%CI:0.13-0.87), injected drugs (aRR = 0.35, 95%CI:0.18-0.68), or used gamma-hydroxybutyrate (GHB) (aRR = 0.41, 95%CI:0.21-0.78). Symptoms of anxiety or depression were not associated with reductions in MA use. Conclusions: Social connection and drug-related factors surrounding MA use were associated with reductions, but anxiety and depressive symptomatology were not. Incorporating socialization and polysubstance-related components with MA reduction may help in developing efficacious interventions toward reducing MA use for gbMSM.

Effects of resistance training on depression and cardiovascular disease risk in Black men: Protocol for a randomized controlled trial

BACKGROUND

Depression is severely undertreated in Black men. This is primarily because Black men are less likely to seek traditional psychiatric treatment, have less access and more barriers to treatment, and perceive more stigma associated with treatment. Depression contributes to cardiovascular disease (CVD), and Black men have the highest rate of mortality from CVD. Resistance training (RT) can have beneficial effects on both depression and CVD. This study will be the first randomized controlled trial to test the effects of RT on depression and cardiovascular health in a sample of depressed Black men.

METHOD/DESIGN

Fifty Black men with clinically significant symptoms of depression will be randomized to either (a) a 12-week RT or (b) an attention-control group. Behavioral Activation techniques will be used to support adherence to home-based RT goals. Both groups will meet on-site twice/week during the 12-week program, and follow-up assessments will occur at the end-of-treatment and 3 months post-treatment. Qualitative interviews will be conducted after the 3-month follow-up. The objectives of this study are (1) to assess the feasibility and acceptability of recruitment, retention, and intervention procedures, (2) to obtain preliminary evidence of efficacy, and (3) to explore potential mediators of the effects of RT on depression.

DISCUSSION

This study will advance the field of minority men's health by producing new data on the effects of RT for depression, the potential mechanisms of action that may support its use, and its effects on markers of CVD risk in Black men.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03107039).

Cognitive Behavioral Therapy for Trauma and Self-Care (CBT-TSC) in Men Who have Sex with Men with a History of Childhood Sexual Abuse: A Randomized Controlled Trial

To address childhood sexual abuse (CSA) related distress and HIV risk in men who have sex with men (MSM) using cognitive-behavioral therapy for trauma and self-care (CBT-TSC), which is a novel intervention integrating HIV risk reduction with modified cognitive and behavioral therapy strategies for post-traumatic stress. We compared CBT-TSC to HIV voluntary counseling and testing (VCT)-only in an initial 2-arm RCT in 43 HIV-negative MSM at with a history of CSA and HIV risk. Serodiscordant condomless anal/vaginal sex (CAS; CAS with HIV-postive or HIV unknown status partners) and posttraumatic stress disorder (PTSD) symptoms (Davidson Trauma Scale: total score and avoidance, intrusions, hyperarousal subscales) were outcomes immediately post-treatment, and at 6- and 9-month follow-up. At post-treatment, CBT-TSC had decreased odds (approximately 60%) of any CAS and greater reductions in CAS compared to VCT-only. Additionally, the CBT-TSC condition experienced greater reductions in total PTSD and avoidance symptoms. At the follow-up visits, CBT-TSC condition had significant reductions in the odds of any CAS and reductions in CAS. However, for PTSD symptoms, only the avoidance subscale remained significantly different compared to VCT-only. CBT-TSC is a potentially efficacious approach to address HIV risk in MSM with a CSA history, with replication and extension in a larger trial needed. This proof-of-concept trial is the first to integrate the treatment of a commonly occurring mental-health syndemic problem in MSM with a health psychology approach to self-care in MSM.Trial Registration Clinicaltrials.gov NCT01266122.

An initial randomized controlled trial of behavioral activation for treatment of concurrent crystal methamphetamine dependence and sexual risk for HIV acquisition among men who have sex with men

Men who have sex with men (MSM) continue to be the largest risk group for HIV infections in the U.S., where crystal methamphetamine abuse heightens risk for HIV infection through greater engagement in condomless anal sex (CAS). Existing treatments lack 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. We hypothesize, for MSM abusing crystal methamphetamine, re-learning how to engage in non-drug-using aspects of life would facilitate their ability to benefit from sexual risk reduction (SRR) counseling. Project IMPACT was a pilot randomized-controlled-trial. Forty-six MSM at sexual risk of acquiring HIV who met DSM-IV criteria for crystal methamphetamine dependence were enrolled. Of those MSM, 41 were randomized: 21 were assigned to the intervention, two sessions of SRR, ten sessions of BA with SRR, and one session of relapse prevention; 20 participants were assigned to a control condition (two sessions of SRR). At the acute post-intervention visit, intervention participants reported an average of 3.2 CAS acts with men who were HIV-infected or whose status they did not know, compared to 4.5 among control participants (β = -0.36; 95% CI: -0.69, -0.02; p = 0.035). At the 6-month post-intervention visit, intervention participants reported 1.1 CAS acts with men who were HIV-infected or whose status they did not know compared to 2.8 among control participants (β = -0.95; 95% CI: -1.44, -0.46; p < 0.0001). Similarly, intervention participants reported 1.0 CAS acts under the influence of crystal methamphetamine with men who were HIV-infected or whose status they did not know compared to 2.5 among control participants (β = -0.87; 95% CI: -1.38, -0.36; p = 0.0005). Lastly, intervention participants reported more continuous days abstaining from crystal methamphetamine compared to control (50.1 vs. 39.0, respectively) (β = 0.25; 95% CI: 0.16, 0.34; p < 0.0001). Findings are encouraging, provide evidence of feasibility and acceptability, and demonstrate initial efficacy for reducing sexual risk for HIV and crystal methamphetamine use.

Randomized Control Trial of Culturally Adapted Cognitive Processing Therapy for PTSD Substance Misuse and HIV Sexual Risk Behavior for Native American Women

An overlooked sequela of HIV risk is trauma exposure, yet few HIV interventions address trauma exposure, mental health, and substance misuse. In a two-arm randomized controlled trial 73 Native American women were randomized to a culturally-adapted Cognitive Processing Therapy (CPT) or 6-weeks waitlist. Outcomes assessed: PTSD symptom severity, alcohol use frequency, substance abuse or dependence diagnosis, and high-risk sexual behavior defined as vaginal/anal intercourse (a) under the influence of alcohol and/or illicit substances, (b) with a partner who was concurrently sexually active with someone else, and/or (c) with more than one partner in the past 6 weeks. Among immediate intervention participants, compared to waitlist participants, there were large reductions in PTSD symptom severity, high-risk sexual behavior, and a medium-to-large reduction in the frequency of alcohol use. CPT appears to improve mental health and risk behaviors, suggesting that addressing PTSD may be one way of improving HIV-risk related outcomes.

HIV prevention intervention for substance users: a review of the literature

Background

Behavioral Interventions are needed to prevent HIV in substance users, which is associated with higher risk for contracting HIV via unprotected sexual intercourse or syringe-based exposure. We reviewed universal HIV prevention interventions targeting intravenous drug users (IDUs) and non-IDUs (NIDUs) to identify which prevention interventions are the most effective at reducing HIV transmission risk among IDU’s and NIDU’s and identify gaps in the literature.

Methods

A PubMed literature review (1998–2017), limiting studies to universal HIV prevention interventions targeting adult HIV-negative substance users. Interventions were compared across sample sizes, sociodemographic, intervention setting, study design, use of theoretical models, and intervention effects.

Results

Of 1455 studies identified, 19 targeted IDUs (n = 9) and NIDUs (n = 10). Both IDU and NIDU studies were conducted in substance use treatment centers and included both group (44% vs. 73%) and individual-based (56% vs. 27%) methods; only one NIDU study used a couple-based intervention. All IDU, and 89% of NIDU, studies used explanatory and behavior-change theoretical models to guide selection of intervention mechanisms. Reduction in frequency of risky sexual behaviors were observed in 33% IDU and 64% NIDU studies, where 56% of IDU studies effectively increased drug use-related hygiene and 67% decreased frequency of injections. Eight studies included start-of-study HIV testing and five examined HIV seroconversion.

Conclusion

The interventions reviewed demonstrate promising results for decreasing risky sexual practices for NIDUs and reducing high-risk drug practices for IDUs, thereby reducing HIV transmission risk. Future studies should include HIV testing and measurement of HIV seroconversion to fully elucidate intervention effects.

Interventions to address substance use and sexual risk among gay, bisexual and other men who have sex with men who use methamphetamine: A systematic review

BACKGROUND

Methamphetamine use is common among some populations of gay, bisexual and other men who have sex with men (gbMSM). This study reviewed the status of research on the efficacy of interventions that address harms among gbMSM who use methamphetamine.

METHODS

We searched MEDLINE, PsycINFO, CINAHL, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar to identify publications from inception to October 23, 2017, that assessed an intervention addressing methamphetamine use among gbMSM.

RESULTS

Of 1896 potential studies and 935 unique articles screened for inclusion, 28 eligible studies assessed 26 different interventions in the following categories: pharmacological (n = 5); psychosocial (n = 20); harm reduction (n = 1). Given that outcome variables were measured in highly variable ways, we were unable to conduct a meta-analysis of intervention effects. However, 22 studies reported a statistically significant effect on one or more methamphetamine-related outcomes. Among 21 studies that included measures of sexual health-related outcomes, 18 reported a significant effect on one or more sexual health-related outcomes, and 15 of those reported a concurrent effect on both drug- and sexual health-related outcomes.

CONCLUSIONS

This is the first review to provide compelling evidence that integrating interventions to address both drug- and sexual-related harms for gbMSM who use methamphetamine can be efficacious. Future research should focus on identifying differential effects of various intervention approaches by social positioning, as well as prioritize future evaluations of integrated harm reduction interventions (e.g., the distribution of harm reduction kits within sexual health care settings).

Changing the odds: motives for and barriers to reducing HCV-related sexual risk behaviour among HIV-infected MSM previously infected with HCV

Background

Among HIV-infected MSM who have been treated for HCV infection, the HCV reinfection rate is high. It is therefore essential to understand their perceptions of HCV risk behaviour and risk-reducing strategies.

Methods

This qualitative study among 20 HCV-infected MSM, the majority treated in the era before direct acting antivirals, provides insight into their ideas, motives, and barriers concerning HCV risk reduction, and aims to strengthen prevention strategies for both primary HCV infection and HCV reinfection.

Results

The strongest motive to implement risk reduction strategies was the reward of avoiding HCV retreatment and its side effects, but this may change with the current implementation of less burdensome HCV treatment. Also, the sexual risk norms in the MSM scene, including social pressure towards risk-taking, HCV stigma, and non-disclosure of HCV status, all form barriers to safe sex. Drug use, strongly present in the context of clubs and group sex, directly impedes the self-efficacy of men to take risk reduction measures.

Conclusions

Tailored prevention messages, empowerment of self-efficacy for risk reduction, and more insight into risk behaviour over time are ingredients for effective HCV prevention among these men.

Differentially classified methamphetamine-using men who have sex with men: A latent class analysis

CONTEXT

Substance use interventions for methamphetamine-using men who have sex with men (MSM) are limited by the assumption that they are a uniform group. We hypothesized that an LCA would identify distinct patterns of substance use and demographic and psychosocial variables associated with different substance-using groups would aid in understanding distinctions. Using cross-sectional data from 343 methamphetamine-using MSM, we conducted an LCA to model the patterns of polysubstance use then examined how the classes varied on psychosocial variables defined by the Information-Motivation-Behavioral Skills (IMB) model.

FINDINGS

Because we were interested in identifying patterns of polysubstance use (PSU) among our sample, we identified four classes: minimal PSU, marijuana PSU, cocaine/hallucinogens PSU, and designer drugs/heroin PSU. Men in the marijuana PSU class were less likely to have positive attitudes towards methamphetamine than participants in the other three classes. Men in the Cocaine and Hallucinogens PSU class were more likely to have higher PANAS scores (OR = 13.00 [3.25, 52.07]) compared to the other classes, and they were more likely to have higher self-efficacy to enact safer substance use strategies (OR = 10.72 [3.23, 35.47]). MSM in the Designer Drug and Heroin PSU class were more likely to have a diagnosis of Hepatitis B (OR = 4.07 [0.86, 19.36] despite having higher knowledge of sexual health practices (OR = 0.55 [0.36, 0.84].

CONCLUSIONS

Differential classification for methamphetamine-using MSM suggests an opportunity for tailored interventions and secondary prevention programs. By understanding how men vary on illicit substance use, interventionists can routinely screen and link men before they potentially progress to another classification.

Effects of behavioural activation on substance use and depression: a systematic review

INTRODUCTION

Substance use and depression co-occurrence is a frequent phenomenon and an important public health concern. Given the clinical implications and the high prevalence of both disorders, effective interventions are needed.

METHODS

The aim of this study is to review Behavioural Activation (BA) intervention effects to improve substance use behaviour and depression. A systematic review was conducted using MEDLINE, EMBASE, and PsycINFO. The Effective Public Health Practice Project Quality Assessment Tool (EPHPP) was used to assess the methodological quality of included studies. Two authors independently screened titles and abstracts, reviewed selected studies, and extracted data.

RESULTS

Of the 7286 studies identified, eight met inclusion criteria. Designs of the studies included six randomized controlled trials (RCTs), and two pre-post design studies. One trial received weak methodological quality, six moderate, and one strong. Three studies addressed smoking behaviour; two targeted opiate dependence; two focused on alcohol/drug dependence; and, one on crystal methamphetamine abuse. Results showed that BA had a positive effect on substance use outcomes in seven of the eight reviewed studies, and improved depression over time in six studies.

CONCLUSIONS

Although studies conducted so far are limited by their heterogeneity and sample sizes, results are promising. There is a need of well controlled and powered studies to establish and to confirm the effectiveness of BA for the treatment of substance use and depression. Future studies should include stronger methodological designs, larger sample sizes, and long-term follow-ups.

TRIAL REGISTRATION

PROSPERO registration number: CRD42016039412 .

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

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.

Mood, Meth, Condom Use, and Gender: Latent Growth Curve Modeling Results from a Randomized Trial

Methamphetamine use poses increased risk for HIV and other sexually transmitted infections. There is robust evidence that methamphetamine use increases sexual risk behavior, like condomless sex, primarily among men who have sex with men but also among heterosexual women and men. Gender differences have been found among women and men who use meth, and there is a high degree of interconnectedness between meth use, depression, and condomless sex. The aims of the current study are to evaluate the efficacy of a theory-based, tri-focal intervention designed to reduce depression, meth use, and condomless sex among women and men, and to examine gender as a moderator of efficacy. A total of 432 HIV-negative women and men who use meth participated in a two-arm randomized controlled trial and completed baseline and follow-up assessments at 4, 8, and 12 months. We used latent growth curve modeling techniques to analyze the data. Results showed that while all participants exhibited reductions in depression, meth use, and condomless sex, the intervention and comparison groups did not differ in changes over time. However, we did find a significant gender moderation effect, such that among men, those in the intervention arm reported greater reductions in meth use relative to those in the comparison group; reduced meth use was associated with reduced condomless sex, but not depression. In contrast, women in the intervention condition did not differ from women in the comparison condition in changes in any of the three outcome variables. Interventions targeting heterosexual women and men who use meth must be gender-specific, and take into account the unique vulnerabilities and experiences of women, including the perceived positive aspects of using meth, gendered power dynamics, higher depression, and violence.

Testing the Efficacy of Combined Motivational Interviewing and Cognitive Behavioral Skills Training to Reduce Methamphetamine Use and Improve HIV Medication Adherence Among HIV-Positive Gay and Bisexual Men

Prior research has identified subgroups of HIV-positive gay and bisexual men (GBM) based upon information, motivation, and behavioral skills (IMB) profiles related to HIV medication adherence and methamphetamine use. We conducted a randomized controlled trial of a combined motivational interview (MI) and cognitive behavioral therapy (CBT) intervention tailored specifically to the unique context of HIV-positive GBM, and tested whether IMB profiles moderated treatment effects. HIV-positive GBM (N = 210) were randomized to MI + CBT or an attention-matched education control. Both conditions resulted in reduced methamphetamine use, improved medication adherence (and higher CD4 and lower viral loads), and fewer acts of condomless anal sex at 3, 6, 9 and 12 months post-intervention. Furthermore, the MI + CBT condition achieved greater improvements in medication adherence for men who had greater barriers to change compared to similarly-classified men in the control condition, suggesting the importance of pre-intervention profiles for tailoring future interventions.

A randomized controlled efficacy trial of behavioral activation for concurrent stimulant use and sexual risk for HIV acquisition among MSM: project IMPACT study protocol

BACKGROUND

In the United States, problematic stimulant use is a prevalent and difficult to treat problem among men who have sex with men (MSM), as well as a major driver of HIV transmission through the large number of sexual partners and concomitant condomless anal sex (CAS). Evidence-based behavioral studies that address problematic stimulant use in MSM at risk for HIV infection are also lacking. In this paper, we describe the design of a behavioral intervention trial to reduce sexual risk behavior and stimulant use in HIV-uninfected MSM.

METHODS

This study, funded by the National Institute on Drug Abuse (NIDA), is a randomized controlled trial (RCT) testing an integrated HIV risk reduction and behavioral activation counseling intervention (IMPACT) for HIV-uninfected, stimulant using MSM in Boston, MA, and Miami, FL. Participants are randomized (2:2:1) to either (1) the IMPACT intervention; (2) a relaxation condition, an active therapy time- and intensity-matched control; or (3) a standard of care risk reduction counseling comparison. At enrollment, all participants receive an HIV test and pre- and post-test counseling. The primary outcome is the difference in the rate of change in the number of self-reported condomless anal sex acts without the protection of consistent Pre-Exposure Prophylaxis (PrEP) use, as well as reductions in stimulant use during the prior 4-months. Major assessments are conducted at baseline, 4-, 8-, and 12-month follow-up visits.

DISCUSSION

Effective and sustainable behavioral interventions are sorely needed to reduce HIV acquisition in stimulant using MSM at risk for HIV infection. In this study, we will evaluate the evidence of efficacy of the IMPACT intervention to reduce HIV acquisition in HIV-uninfected, stimulant-using MSM. If found effective, the intervention tested here holds promise for being readily integrated into real-world clinical settings.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT03175159 , registered June 5, 2017.

Sexualised drug taking among men who have sex with men: a systematic review

AIMS:

Sexualised drug taking is increasingly reported on national and international levels. We aim to review existing evidence of the relationship between recreational drug use (RDU) and sexual intercourse among men who have sex with men (MSM).

METHODS:

We reviewed published abstracts and full articles identified from Cochrane, MEDLINE and Embase databases from November 2010 to 2017. We included any existing studies investigating RDU in MSM and at least one of the following: high-risk sexual practices, sexually transmitted infections (STIs) or barriers to accessing specialist support.

RESULTS:

In total, 112 studies were included. Of them, 38 studies specifically reported the prevalence of chemsex-related drug use. Links with sexualised drug taking and high-risk sexual practices including condomless sex and group sex were reported by several studies. Recreational drug use in the sexual setting appears linked to the acquisition of STIs, including hepatitis C, syphilis and gonorrhoea. Reports of adverse mental health outcomes are increasingly described, with several studies documenting chemsex-related inpatient admission. A paucity of research addressing barriers to those accessing specialist drug support services was identified.

CONCLUSION:

This review demonstrates the complex interplay between recreational drug use, high-risk sexual practices and STIs. It identifies the description of adverse mental health outcomes in the chemsex setting, thus highlighting the need for a multidisciplinary approach across specialties in the management of those adversely affected. Finally, it illuminates the need for future research into perceived barriers of those who require access to support services to ensure timely and comprehensive support provision.

The clinical effectiveness of individual behaviour change interventions to reduce risky sexual behaviour after a negative human immunodeficiency virus test in men who have sex with men: systematic and realist reviews and intervention development

BACKGROUND

Men who have sex with men (MSM) experience significant inequalities in health and well-being. They are the group in the UK at the highest risk of acquiring a human immunodeficiency virus (HIV) infection. Guidance relating to both HIV infection prevention, in general, and individual-level behaviour change interventions, in particular, is very limited.

OBJECTIVES

To conduct an evidence synthesis of the clinical effectiveness of behaviour change interventions to reduce risky sexual behaviour among MSM after a negative HIV infection test. To identify effective components within interventions in reducing HIV risk-related behaviours and develop a candidate intervention. To host expert events addressing the implementation and optimisation of a candidate intervention.

DATA SOURCES

All major electronic databases (British Education Index, BioMed Central, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Educational Resource Index and Abstracts, Health and Medical Complete, MEDLINE, PsycARTICLES, PsycINFO, PubMed and Social Science Citation Index) were searched between January 2000 and December 2014.

REVIEW METHODS

A systematic review of the clinical effectiveness of individual behaviour change interventions was conducted. Interventions were examined using the behaviour change technique (BCT) taxonomy, theory coding assessment, mode of delivery and proximity to HIV infection testing. Data were summarised in narrative review and, when appropriate, meta-analysis was carried out. Supplemental analyses for the development of the candidate intervention focused on post hoc realist review method, the assessment of the sequential delivery and content of intervention components, and the social and historical context of primary studies. Expert panels reviewed the candidate intervention for issues of implementation and optimisation.

RESULTS

Overall, trials included in this review (n = 10) demonstrated that individual-level behaviour change interventions are effective in reducing key HIV infection risk-related behaviours. However, there was considerable clinical and methodological heterogeneity among the trials. Exploratory meta-analysis showed a statistically significant reduction in behaviours associated with high risk of HIV transmission (risk ratio 0.75, 95% confidence interval 0.62 to 0.91). Additional stratified analyses suggested that effectiveness may be enhanced through face-to-face contact immediately after testing, and that theory-based content and BCTs drawn from 'goals and planning' and 'identity' groups are important. All evidence collated in the review was synthesised to develop a candidate intervention. Experts highlighted overall acceptability of the intervention and outlined key ways that the candidate intervention could be optimised to enhance UK implementation.

LIMITATIONS

There was a limited number of primary studies. All were from outside the UK and were subject to considerable clinical, methodological and statistical heterogeneity. The findings of the meta-analysis must therefore be treated with caution. The lack of detailed intervention manuals limited the assessment of intervention content, delivery and fidelity.

CONCLUSIONS

Evidence regarding the effectiveness of behaviour change interventions suggests that they are effective in changing behaviour associated with HIV transmission. Exploratory stratified meta-analyses suggested that interventions should be delivered face to face and immediately after testing. There are uncertainties around the generalisability of these findings to the UK setting. However, UK experts found the intervention acceptable and provided ways of optimising the candidate intervention.

FUTURE WORK

There is a need for well-designed, UK-based trials of individual behaviour change interventions that clearly articulate intervention content and demonstrate intervention fidelity.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42014009500.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Number of Psychosocial Strengths Predicts Reduced HIV Sexual Risk Behaviors Above and Beyond Syndemic Problems Among Gay and Bisexual Men

Syndemics research shows the additive effect of psychosocial problems on high-risk sexual behavior among gay and bisexual men (GBM). Psychosocial strengths may predict less engagement in high-risk sexual behavior. In a study of 470 ethnically diverse HIV-negative GBM, regression models were computed using number of syndemic psychosocial problems, number of psychosocial strengths, and serodiscordant condomless anal sex (CAS). The number of syndemic psychosocial problems correlated with serodiscordant CAS (RR = 1.51, 95% CI 1.18-1.92; p = 0.001). When adding the number of psychosocial strengths to the model, the effect of syndemic psychosocial problems became non-significant, but the number of strengths-based factors remained significant (RR = 0.67, 95% CI 0.53-0.86; p = 0.002). Psychosocial strengths may operate additively in the same way as syndemic psychosocial problems, but in the opposite direction. Consistent with theories of resilience, psychosocial strengths may be an important set of variables predicting sexual risk behavior that is largely missing from the current HIV behavioral literature.

Optimizing Contingency Management with Methamphetamine-Using Men who Have Sex with Men

Among men who have sex with men (MSM), methamphetamine use is associated with multiple, overlapping syndemic conditions including increased risk for HIV seroconversion and onward HIV transmission. Contingency management (CM) is an evidence-based, behavioral intervention implemented to curb methamphetamine use and optimize HIV/AIDS prevention among MSM in San Francisco since 2003. We conducted a program evaluation to document the evolution of this 12-week CM program to include delivery of brief, individual counseling incorporating motivational interviewing and behavioral skills. A drop-in group delivered concurrently with CM urine-screening visits also provides peer support as well as referrals for other social and medical services. From December 2011-October 2013, a total of 131 clients enrolled in the CM program and provided a median of 22 urine samples (Interquartile Range = 10-34) that were non-reactive for methamphetamine. Findings support the feasibility and acceptability of integrating individual and group counseling with community-based CM for methamphetamine-using MSM.

Critical Review: When the Party is Over: A Systematic Review of Behavioral Interventions for Substance-Using Men Who Have Sex with Men

Because problematic patterns of alcohol and other substance use are prevalent drivers of the HIV/AIDS epidemic, comprehensive interventions are needed for substance-using men who have sex with men (SUMSM). We conducted a systematic review of 12 randomized controlled trials (RCTs) of behavioral interventions for reducing condomless anal intercourse (CAI) in SUMSM. Three RCTs observed that cognitive behavioral or motivational interviewing interventions achieved a 24% to 40% decrease in CAI. Interventions also tended to demonstrate greater efficacy for reducing CAI and substance use among those who had lower severity of substance use disorder symptoms. Although behavioral interventions for SUMSM are one potentially important component of biobehavioral HIV/AIDS prevention, further research is needed to examine whether integrative approaches that cultivate resilience and target co-occurring syndemic conditions demonstrate greater efficacy. Multilevel intervention approaches are also needed to optimize the effectiveness of pre-exposure prophylaxis and HIV treatment as prevention with SUMSM.

Behavioral activation for smoking cessation and mood management following a cardiac event: results of a pilot randomized controlled trial

Background

Smoking cessation following hospitalization for Acute Coronary Syndrome (ACS) significantly reduces subsequent mortality. Depressed mood is a major barrier to cessation post-ACS. Although existing counseling treatments address smoking and depression independently in ACS patients, no integrated treatment addresses both. We developed an integrated treatment combining gold standard cessation counseling with behavioral activation-based mood management; Behavioral Activation Treatment for Cardiac Smokers (BAT-CS). The purpose of this pilot randomized controlled trial was to test feasibility, acceptability, and preliminary efficacy of BAT-CS vs. Standard of Care (SC).

Methods

Participants were recruited during hospitalization for ACS and were randomly assigned to BAT-CS or SC. The nicotine patch was offered in both conditions. Smoking, mood, and stress outcomes were collected at end-of-treatment and 24-week follow-up.

Results

Fifty-nine participants (28 BAT-CS, 31 SC) were recruited over 42 weeks, and assessment completion was above 80% in both conditions. Treatment acceptability and fidelity were high. At 24 week follow-up adjusted odds ratios favoring BAT-CS were 1.27 (95% CI: 0.41–3.93) for 7-day point prevalence abstinence and 1.27 (95% CI: 0.42–3.82) for continuous abstinence. Time to first smoking lapse was significantly longer in BAT-CS (62.4 vs. 31.8 days, p = 0.03). At 24-weeks, effect sizes for mood and stress outcomes ranged from η²_partial of.07–.11, with significant between treatment effects for positive affect, negative affect, and stress.

Conclusions

The design of this study proved feasible and acceptable. Results provide preliminary evidence that combining behavioral activation with standard smoking cessation counseling could be efficacious for this high risk population. A larger trial with longer follow-up is warranted.

Trial registration

NCT01964898. First received by clinicaltrials.gov October 15, 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4250-7) contains supplementary material, which is available to authorized users.

Mental health in 2020 for men who have sex with men in the United States

Despite continued advances in HIV prevention and treatment, gay and bisexual men and other men who have sex with men (MSM) remain the population most impacted by HIV/AIDS in the US and many other Western countries. Additionally, MSM are disproportionately affected by various psychological problems, including depression, distress, trauma and substance use. These challenges frequently co-occur, and are associated with higher rates of behaviours related to HIV acquisition and transmission, HIV infection, and, for those living with HIV/AIDS, lower levels of treatment engagement. Moreover, racial disparities exist among MSM in the US; for example, young African American MSM bear a disproportionate burden of the continuing HIV epidemic, likely related to disparate HIV prevalence in partner pools as well as long-standing structural inequities. In this review, the mental health challenges facing MSM primarily in the US, related to HIV and STI prevention and across the HIV care cascade, including HIV diagnosis, engagement and retention in care, and antiretroviral adherence, are illustrated. Disparities among MSM including racial and ethnic, age-related and structural barriers associated with HIV prevention and treatment, as well as current interventions, are also described. Moving forward towards 2020, resources will be needed to assess and implement scalable intervention strategies to address psychological and social barriers to HIV and STI risk reduction and treatment for MSM, with a particular focus on the most vulnerable subpopulations. As access to prevention and treatment strategies expand, and new breakthroughs continue to emerge, behavioural strategies will continue to be needed to reduce risk and increase uptake and engagement among MSM most at risk through 2020 and beyond.

Differences in Attitudes About HIV Pre-Exposure Prophylaxis Use Among Stimulant Versus Alcohol Using Men Who Have Sex with Men

Alcohol and stimulant use are independently associated with increased HIV acquisition among men who have sex with men (MSM). We assessed differences in acceptability and perceived barriers to uptake of pre-exposure prophylaxis (PrEP) among stimulant and alcohol-using MSM in Boston. From September 2012-2013, a quantitative assessment was conducted with 254 MSM respondents who reported recent condomless sex in the context of concurrent stimulant (crack/cocaine and crystal methamphetamine; n = 132) or alcohol use (n = 122). Thirteen (5.1  %) reported previous PrEP use. In multivariable models, stimulant users were more likely to be concerned that substance use would affect PrEP adherence (aRR = 2.79, 95  % CI 1.63-4.77), and were less concerned about HIV stigma as a barrier to PrEP uptake (aRR = 0.52, 95  % CI 0.30-0.90) compared to alcohol users. Barriers to PrEP uptake and adherence differ by type of substance used. Different strategies may be required for PrEP implementation among MSM who use stimulants and alcohol.

A Pilot Trial of a Sexual Health Counseling Intervention for HIV-Positive Gay and Bisexual Men Who Report Anal Sex without Condoms

Background

Even in the presence of promising biomedical treatment as prevention, HIV incidence among men who have sex with men has not always decreased. Counseling interventions, therefore, continue to play an important role in reducing HIV sexual transmission behaviors among gay and bisexual men and other men who have sex with men. The present study evaluated effects of a small-group counseling intervention on psychosocial outcomes and HIV sexual risk behavior.

Method

HIV-positive (HIV+) peer counselors administered seven 2-hour counseling sessions to groups of 5 to 8 HIV+ gay and bisexual men. The intervention employed information provision, motivational interviewing, and behavioral skills building to reduce sexual transmission risk behaviors.

Results

There was a significant reduction in condomless anal sex (CAS) with HIV-negative and unknown HIV-status partners, from 50.0% at baseline to 28.9% of the sample at 3-month follow-up. Findings were robust even when controlling for whether the participant had an undetectable viral load at baseline. Significant reductions were also found in the two secondary psychosocial outcomes, loneliness and sexual compulsivity.

Conclusions

The findings provide preliminary evidence that this intervention may offer an efficient way of concurrently reducing CAS and mental health problems, such as sexual compulsivity and loneliness, for HIV+ gay and bisexual men.

Trial Registration

ClinicalTrials.gov NCT02546271

Feasibility of Pairing Behavioral Activation With Exercise for Women With Type 2 Diabetes and Depression: The Get It Study Pilot Randomized Controlled Trial

Major depressive disorder is often comorbid with diabetes and associated with worse glycemic control. Exercise improves glycemic control and depression, and thus could be a parsimonious intervention for patients with comorbid diabetes and major depression. Because patients with diabetes and comorbid depression are often sedentary and lack motivation to exercise, we developed a group exercise intervention that integrates strategies from behavioral activation therapy for depression to increase motivation for and enjoyment of exercise. We conducted a 6-month pilot randomized controlled trial to test the feasibility of the behavioral activation exercise intervention (EX) for women with diabetes and depression. Of the 715 individuals who contacted us about the study, 29 participants were randomized to the EX condition or an enhanced usual care condition (EUC), which represents 4.1% of participants who initially contacted us. Inclusion criteria made recruitment challenging and limits the feasibility of recruiting women with diabetes and depression for a larger trial of the intervention. Retention was 96.5% and 86.2% at 3 and 6months. Participants reported high treatment acceptability; use of behavioral activation strategies and exercise class attendance was acceptable. No condition differences were observed for glycemic control, depressive symptoms, and physical activity, though depressive symptoms and self-reported physical activity improved over time. Compared to participants in the EUC condition, participants in the EX condition reported greater exercise enjoyment and no increase in avoidance behavior over time. Using behavioral activation strategies to increase exercise is feasible in a group exercise setting. However, whether these strategies can be delivered in a less intensive manner to a broader population of sedentary adults, for greater initiation and maintenance of physical activity, deserves further study.