In the United States, methamphetamine use is endemic among gay and bisexual males (GBM), particularly in major urban centers such as New York City, Los Angeles and San Francisco where the drug is easily accessible and integrated into the social and sexual contexts of GBM (Halkitis, Parsons, & Stirratt, 2001
; Mansergh et al., 2001
; Mattison, Ross, Wolfson, & Franklin, 2001
; Reback, 1997
; Woody et al., 2001
). Methamphetamine abuse is a major public health concern for communities of GBM, with high prevalence (>10%) of use of the drug reported in New York (Grov, Bimbi, Nanin, & Parsons, 2006
), Los Angeles, San Francisco (Stall et al., 2001
) and among GBM who frequent the Internet (Hirshfield, Remien, Humberstone, Walavalkar, & Chiasson, 2004
) and sex venues (Halkitis, Fischgrund, & Parsons, 2005
) to find sexual partners.
Among GBM who use methamphetamine, the drug is frequently integrated into sexual behaviors that confer risk, providing opportunities for transmission of sexually transmitted diseases, including HIV (Buchacz et al., 2005
; Chesney, Barrett, & Stall, 1998
; Plankey et al., 2007
). In the process of using the drug, methamphetamine often becomes incorporated with many of the identities held by the user, including the identity as a gay or bisexual man, as a methamphetamine user, and as a person living with (or without) HIV (Reback, 1997
). Given the association between methamphetamine use, high-risk sexual behaviors and HIV seropositivity (Shoptaw & Reback, 2006
), the development of a low-cost, efficacious and evidenced-based intervention for use in community settings would serve as a tremendous public health benefit.
Our initial efforts to intervene on the interwoven problems of methamphetamine misuse and high-risk sexual behaviors yielded a tailored, gay-specific, cognitive behavioral therapy (GCBT) intervention that integrated core elements from a standard cognitive behavioral therapy (CBT) intervention (Rawson et al., 1995
) with elements that addressed cultural and social aspects of methamphetamine use by GBM. This tailored intervention equally addressed methamphetamine use and HIV-related sexual risk reductions among GBM. In the initial randomized controlled trial, the GCBT intervention was developed and evaluated against three evidence-based conditions: contingency management (CM), standard CBT, and a combination of standard CBT+CM. The original GCBT intervention consisted of 48 sessions delivered in group format over 16 weeks and was shown to significantly reduce sexual risk behaviors over standard CBT during treatment, with comparable reductions of methamphetamine use at follow-up visits to one-year (Reback, Larkins, & Shoptaw, 2004
; Shoptaw et al., 2005
Developmental work continued on the intervention in a replication study that evidenced the specificity of GCBT to statistically reduce methamphetamine use compared to a control condition (Gay Social Support Therapy [GSST]). In broader groups of substance-using GBM, i.e., abuse of all stimulants and alcohol, both GCBT and the comparator GSST performed equally in reducing substance use during treatment and to one year, with GCBT outperforming GSST in reducing methamphetamine use among methamphetamine abusing GBM (Shoptaw et al., 2008
In this study, we evaluate whether the size of outcomes in retention, methamphetamine use, and sexual risk behaviors between a final modification to the GCBT intervention for methamphetamine-abusing GBM differed from those measured using the original and replication versions of the GCBT intervention. In this final stage of therapy development, GCBT was coupled with CM in order to combine optimally effective interventions for reducing HIV-related sexual behaviors (GCBT) and methamphetamine use (CM).
The modified GCBT+CM intervention was specifically designed to be cost and time effective for community application, thus moving research on efficacious treatments into practice. This open label study continued development of the GCBT intervention by adopting, tailoring and transferring the original intervention for use in a community-based HIV prevention setting. Shortened, modified versions of the original and replicated GCBT interventions would increase feasibility of implementation in community-based organizations. Modifications consisted of reducing the intervention from 16 weeks and 48 sessions to 8 weeks and 24 sessions while maintaining the core elements. Given that the modified intervention has fewer sessions and is easier to implement, outcome findings that demonstrated only minor reductions in outcomes from the more expansive model would be important to advise adaptation of evidence-based interventions into community settings that intervene with this high-risk population.
Given the reductions in intensity and coverage of drug treatment, this open label trial predicted that effect sizes for outcomes when using the modified GCBT+CM intervention would be significantly lower than those for the original GCBT intervention in reducing methamphetamine use and HIV-sexual risk behaviors.