Despite the high prevalence of alcohol and cocaine use among PLWHA and its deleterious effect on HIV clinical outcomes, there are few risk reduction interventions for PLWHA who abuse alcohol and non-injection drugs. The results of this randomized controlled trial demonstrate that LIFT, a theoretically-grounded coping group intervention designed specifically for men and women with HIV and CSA, is effective in reducing alcohol and cocaine use. As expected, participants in both the experimental coping and comparison support groups demonstrated reductions in alcohol and cocaine use over time. However, relative to the support group, participants in LIFT had significantly greater reductions in quantity of alcohol consumed and greater likelihood of abstaining from cocaine use over time. Reductions in alcohol and cocaine use were evident immediately post-intervention and sustained at 12-month follow-up for the LIFT condition but not the support condition.
The LIFT intervention used a theoretically-grounded, integrated model to innovatively address stress and coping among PLWHA with complex and repetitive trauma histories. Participants learned how to identify specific stressors related to HIV and CSA and develop problem-focused strategies (e.g., effective communication, problem solving) and emotion-focused strategies (e.g., cognitive restructuring) to cope with changeable and unchangeable stressors, respectively. While the majority of the coping intervention was not specific to substance use, it was frequently identified by participants as a maladaptive coping strategy in response to stress. LIFT participants identified strategies to reduce triggers for substance use, such as regulating negative affect, staying away from certain neighborhoods, breaking off ties with former drug-using peers, and attending 12-step and other self-help programs. The group also focused on the development of skills to more effectively cope with stressors related to living with HIV and CSA within the context of a safe and supportive therapeutic environment. Thus, substance abuse was addressed both directly and indirectly throughout the treatment.
Research consistently demonstrates that CSA is associated with negative physical and mental health outcomes [35
]. Other common sequelae of CSA, such as helplessness, avoidance, and low self-esteem, likely contribute to behavioral risk [44
] and may interfere with the effectiveness of risk reduction interventions [29
]. Unfortunately, despite the elevated rates of sexual trauma among PLWHA, few empirically-supported interventions are tailored to these issues [67
], and none have been found to reduce substance abuse. A common concern among clinicians is that addressing trauma may lead to psychological decompensation and increased substance abuse [48
]. The results of the present trial suggest that trauma can be safely and effectively addressed in a group context with improvements across multiple outcomes, including traumatic stress [50
], sexual risk [51
], and substance use. Based on these findings, it is imperative that future research examine potential mediators of change, such as development of adaptive coping strategies.
It is important to note that LIFT was not designed as a treatment for substance abuse, nor did it target treatment-seeking substance abusers. However, consistent with the greater population of HIV patients, many participants had a history of substance abuse, and a substantial proportion reported current alcohol and illicit drug use. While only two sessions directly addressed substance abuse, the skills taught throughout the intervention were relevant to substance use. Given the positive findings, this intervention should be further tested with PLWHA seeking substance abuse treatment.
Despite the marked reductions in alcohol and cocaine use, there was no change in marijuana use over time in either group. At baseline and throughout the study, approximately one quarter of participants used marijuana. There are a number of possible explanations for this lack of change. While some PLWHA use marijuana primarily to get high, many others use it therapeutically. The purported medicinal benefits of marijuana use are well publicized, and research has established that many PLWHA use marijuana to cope with neuropathy, muscle pain, fatigue, diarrhea, anxiety, and other physical symptoms [70
]. In the current trial, we could not distinguish reasons for marijuana use. Furthermore, relative to alcohol, cocaine, and other “hard drugs,” marijuana may not have been conceptualized as a maladaptive behavior by participants. Thus, participants may not have been motivated to reduce their marijuana use. Alternatively, marijuana use may be difficult to treat in HIV patients. Prior secondary HIV preventions trials have not reported on the effects of the intervention on marijuana use at all [16
] or independent of other substances [17
]. Despite its widespread use as a self-care strategy, marijuana may have deleterious effects on health outcomes, particularly among patients with advanced HIV disease [72
]. Further research is needed to identify effective strategies for reducing marijuana use among PLWHA.
This study had a number of noteworthy strengths. First, it utilized a randomized controlled design with an attention-matched, active comparison intervention and had a 12-month follow-up period following the intervention to assess for sustained treatment effects. Second, substance use was measured at each time point, enabling the modeling of change in substance use over time using a rigorous statistical analysis method. Third, we analyzed the effect of LIFT on multiple measures of substance use, thereby providing a robust and comprehensive picture of the patterns of substance use among participants over time.
The study also had several limitations. First, it was open to all PLWHA with CSA histories, regardless of current substance use. As a result, only 13% were hazardous drinkers and 26% cocaine users at baseline, limiting our power to detect treatment effects. Future studies will need to test whether this intervention is effective among PLWHA seeking treatment for drug and alcohol dependence . Second, recruitment efforts failed to enroll a sufficient number of heterosexual men; therefore, results are generalizable only to women and men who have sex with men. Third, results are based on self-reported substance use, which may be underreported. In the context of a trial that used an attention-matched control condition, this source of bias is less troubling because it tends to bias results towards the null, and is unlikely to vary by condition. Future studies might use urine toxicology tests to corroborate self-reports of drug use. Fourth, the increased attrition at the 12-month visit was suboptimal, but follow-up at all other visits was good. Finally, this was a convenience sample of volunteers living in New York City. Results may not generalize to individuals living in other parts of the world or to those who are unwilling to participate in clinical trials.
In conclusion, results of this randomized controlled trial suggest that LIFT, a theory-based group coping intervention, is effective in promoting sustained reductions in risky drinking and cocaine use among PLWHA who have with histories of CSA. Despite the urgent need for secondary HIV prevention interventions [24
], there is a dearth of empirically-supported treatments for non-injecting substance abusers. By teaching patients how to identify and implement effective coping strategies to manage stressors related to living with HIV and CSA, LIFT had beneficial effects on multiple outcomes, notably traumatic stress, sexual risk, and substance abuse. This approach could be incorporated into community-based mental health services to improve clinical outcomes and quality of life among HIV patients.