HIV Risk Reduction in the National Institute on Drug Abuse Cocaine Collaborative Treatment Study

Studies have shown that cocaine dependence is associated with increased risk for HIV infection. Underlying mechanisms for HIV risk include exchanging sex for drugs, unprotected sex, increased sexual drive resulting from the stimulatory effects of cocaine, multiple injections with contaminated equipment, and impaired judgment in the context of intoxication or the drive to use cocaine. A number of interventions have been developed, including education and counseling, distribution of condoms and bleach, needle exchanges and drug abuse treatment.

HIV risk was evaluated among 487 cocaine-dependent patients recruited from five treatment programs in a trial that examined the efficacy of four outpatient-based psychosocial treatments on reduction of HIV risk. Treatments were offered two to three times per week for six months and consisted of group drug counseling (GDC) or group counseling plus individual drug counseling (IDC), cognitive therapy (CT), or supportive-expressive therapy (SE).

Exclusion criteria included unstable living situations, opioid or polysubstance dependence (current or in early remission), a major psychiatric disorder other than cocaine dependence, needing to be maintained on psychotropic medication, a life-threatening or unstable medical condition, living in a halfway house, or a scheduling problem that made it difficult to keep regular appointments.

The average patient had used cocaine for seven years, with 10 days of use in the last month. Crack smoking was the main route in 79 percent, and HIV risk was mainly due to multiple partners and unprotected sex. Treatment was associated with a decrease in cocaine use from an average of 10 days per month at baseline to one day per month at six months.

Reductions in cocaine use was associated with an average 40 percent decrease in HIV risk across all treatment, gender, and ethnic groups, mainly as a result of fewer sexual partners and less unprotected sex. The combination of IDC and GDC was associated with an equal or even greater reduction in HIV risk than SE or CT in comparisons.

The data, researchers concluded, "show a clear relation between participation in a cocaine treatment program that included risk reduction counseling and reductions in cocaine use and HIV risk from having multiple partners and unprotected sex." However, "because only a subset of those who expressed interest in the study met admission criteria and were randomized, we cannot be certain if these findings apply more generally and to less well-selected patients." "In spite of these limitations, the findings are consistent with a growing literature that participation in treatment of cocaine dependence is associated with a substantial reduction in drug use and HIV risk."

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