Development of CART for HIV adherence and cocaine abuse

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DESCRIPTION (provided by applicant): Medication non-adherence and cocaine use must be reduced among people with HIV to maximize their health. Although non-adherence is not unique to cocaine abusers, these patients are at very high risk of sporadic non-adherence. Intermittent non-adherence puts patients at the highest risk for developing medication-resistant strains of HIV. There is an urgent need for innovative behavioral treatments to address these two problems in a combined approach. Brief interventions are especially needed that could be incorporated into HIV care delivery systems or substance abuse treatment programs. Interventions with two targets are a promising adaptation of motivational interviewing (MI), a brief intervention with good evidence of efficacy in substance abuse. Funds are requested to support the development and pilot testing of a 4 session, dual-focused MI intervention, Cocaine and Adherence Readiness Training (CART) for non-adherent cocaine abusers with HIV. The primary aim of this Stage 1 study is to determine if a larger efficacy trial with the finalized intervention is warranted. We propose to accomplish the following specific aims to provide that evidence. 1) Develop CART, a novel MI-based combination intervention for HIV+ cocaine abusers that increases medication adherence and reduces cocaine use, through conducting pre-pilot sessions, adapting the intervention iteratively, and developing a therapy manual for a pilot trial. CART will include a) assessment of adherence and substance use, attitudes and goals related to change, and a decisional balance exercise, b) personalized feedback of risks, explorations of readiness, and goal setting, c) change planning, eliciting potential barriers to change, updating readiness ratings, and taking initial steps to change, and d) finalizing the change plan, eliciting continued commitment, and building self-efficacy. 2) Develop and validate rating scales of therapist competence to the intervention 3) Develop a training protocol for therapists delivering the experimental intervention and develop ratings of therapist competence and adherence to the intervention. 4) Test the finalized CART intervention vs. a minimal attention control condition in a randomized pilot study (n=50) to estimate effect sizes for primary outcomes; adherence rate and cocaine use severity. 5) Investigate the impact of potential mediator variables including baseline cocaine and adherence levels and patterns, problem severity in each domain, psychiatric comorbidity, and transtheoretical model variables (self-efficacy, stages and processes of change) on intervention completion, research retention, and primary outcomes. This study will yield important clinical innovations to improve the health of cocaine abusers with HIV, provide materials needed for a Stage 2 trial, and provide directions and methods for future research on improving adherence and reducing cocaine use in people with HIV.