Being a PLH creates predictable challenges for adults: staying healthy, stopping sexual transmission acts and coping with HIV-related stressors such as stigma, discrimination and making serostatus disclosures [36
]. The Healthy Living Project was designed to reduce transmission acts, recognizing that changes in sexual behaviors require more comprehensive changes within a person’s life. If the PLH’s motivations for self-preservation and quality of life are not activated, it is unlikely that the PLH will reduce his or her transmission acts altruistically with HIV-negative partners [18
]. Previously, we have demonstrated that this comprehensive prevention approach, delivered over three modules, results in decreases in sexual transmission acts, particularly to HIV-negative partners or partners of unknown serostatus [10
]. These analyses demonstrate that the comprehensive approach also benefits the PLH by substantially and significantly reducing their substance use. Relative to the control condition, the Healthy Living Program reduced effectively PLH’s substance use for alcohol, marijuana and hard drugs. The reductions were sustained for at least 25 months.
It is noteworthy that the intervention does not focus specifically on substance use. The first five-session module of the intervention, for example, focuses on helping participants learn to cope with stressors associated with being HIV-positive and expanding their social support network. This module includes detailed training in coping skills, using an adaptation of Chesney & Folkman’s Coping Effectiveness Training [37
]. We hypothesized that general stress management and problem-solving training would, in turn, help PLH to make more mindful decisions about their sexual behavior. Increased coping skills may also impact substance use, as well as sexual risk. Also, the intervention was designed to be flexible in order to tailor it to the needs of the individual PLH. Thus, PLH who identified substance use as a problem in their lives were encouraged to apply problem-solving techniques to reduce use.
The intervention reduced hard drug use (i.e. heroin, cocaine, crack, speedball, MDMA), as well as alcohol and marijuana use. When examined as individual substances (as opposed to a ‘hard drug’ category), there were significant reductions in methamphetamine/stimulant use, key drugs that reinforce sexual risk behaviors [38
]. In particular, methamphetamine use among MSM has been linked to rising HIV incidence in West Coast AIDS epicenters within the United States [39
]. This is one of the first studies to demonstrate reductions in stimulant use in response to a psychosocial intervention.
We did not find statistically significant intervention effects for some of the drugs classed as ‘more serious’ on our weighted index: crack, cocaine, heroin, opiates and hallucinogens. Because fewer PLH utilize hard drugs (e.g. only 8% used hard drugs daily), while almost all PLH reported either alcohol or drug use, it may be harder to detect an intervention effect. However, PLH with comorbid opiate and cocaine dependency are likely to require specialized treatment to reduce or discontinue using. Our intervention, focusing on coping effectiveness and healthy relationships, created opportunities for referrals for such treatment and may help set the stage for more successful outcomes among hard drug users.
It is noteworthy that there were statistically significant differences in intervention effects based on gender and sexual orientation: women demonstrated the greatest reductions in substance use. MSM and heterosexual men also demonstrated reductions in substance use, but the reductions were not as great as among women. In particular, the reductions in stimulant use in the intervention condition were greater among heterosexual men than MSM. However, there were statistically significant reductions in hard drug use among MSM that were not observed among heterosexual men, and there is little relapse over time. These results are in contrast to the EXPLORE intervention study with seronegative MSM [40
], suggesting that being seropositive is a strong motivator that enhances responsiveness to interventions
This study has several limitations. First, PLH self-reported their substance use. However, similar to other research [25
], reporting biases were minimized by using audio computer-assisted personal interviewing (CAPI) for the substance use reports. Furthermore, the validity of self-reports in prior studies among young PLH were high for all substances except cocaine use and crack [21
]. Secondly, the interventions consisted of multiple components delivered in three modules. We can make no definitive claims about the effects of specific intervention elements on substance use. However, when the components of the comprehensive approach were combined, significant reductions in substance use occurred. Finally, although our sample was large and diverse, it was not recruited to be a representative sample. Our sample is, however, very similar to the socio-demographic profile of PLH in the United States reported to the CDC.
The Healthy Living intervention results in significant reductions in substance use, and was shown previously to produce significant reductions in sexual transmission risk acts [24
]. Reductions in substance use may be a secondary benefit of this intervention but also may contribute directly to reductions in transmission risk.