VOUCHER-BASED INCENTIVES IN A PREVENTION SETTING

描述（由申请人提供）： 无家可归是困扰美国城市的一个重大问题，无家可归的药物滥用者面临着更大的风险。无家可归者、同性恋者和双性恋男性药物滥用者（HGMSA）的艾滋病毒血清阳性率为80%，他们从事性交易并拒绝药物滥用治疗。近30年来，货车尼斯康复之家（VNRH）一直在为加利福尼亚州好莱坞的HGMSA提供治疗服务。1994年，瓦努阿图生殖保健网开始通过其预防司瓦努阿图预防和发展局，向不寻求治疗的高性别、低收入和医疗服务提供者提供基于社区的艾滋病毒预防服务。为行为改变提供积极激励的应急管理干预措施可能特别适合于这一被剥夺权利的高风险群体。具体来说，基于代金券的激励疗法（VBRT）可能特别有效，因为它们已经建立了增加亲社会行为的潜力，成功地与服用药物竞争，并减少药物使用。一项随机对照试验将144例VNPD时非寻求治疗的HGMS分配至VBRT组或对照组（72例/组），持续24周，计划在随机化后7、9和12个月进行随访。VBRT组将获得代金券，以换取完成亲社会和健康的行为和/或提交药物阴性尿液和酒精阴性呼吸样本。优惠券将可兑换位于现场优惠券商店的商品。对照组将收到关于所执行行为以及尿液分析和呼吸酒精测试的反馈，但不会收到这些行为的代金券积分。我们将评估VBRT干预措施在VNPD接受服务的非寻求治疗的HGMSAs中增加亲社会和健康行为并减少药物滥用的有效性。我们还将评估VBRT对与减少伤害方法一致的治疗变化的其他措施的影响，包括减少精神症状，减少注射毒品使用和高风险性行为，增加对预防规划的参与，改善整体功能的不同领域（医疗/社会/职业），并增加改变的准备。此外，我们将研究基线参与者特征是否预测VBRT结果。将VBRT应用于非寻求治疗的HGMSAs以及将VBRT整合到具有减少危害理念的完善预防计划中都具有高度创新性。我们的强化偶然性也将塑造行为步骤，走向更复杂的行为，采用一个基本的操作原则，尚未得到足够的重视。总的来说，我们提出的研究有可能对洛杉矶无家可归者、同性恋和双性恋社区的公共卫生产生重大影响。如果VBRT是有效的激励非寻求治疗HGMSAs在以社区为基础的预防计划，以增加亲社会和健康的行为，减少药物/酒精的使用，建立预防计划可能会修改他们的方法，包括应急管理，并使用它来解决惊人的公共卫生问题HGMSAs每天面临的。

DESCRIPTION (provided by applicant): Homelessness is a significant problem plaguing American cities and homeless substance abusers face increased risks. Homeless, gay and bisexual male substance abusers (HGMSA) suffer 80% HIV seroprevalence, engage in the sex trades and resist treatment for substance abuse. For almost 30 years, the Van Ness Recovery House (VNRH) has been providing treatment services to HGMSAs in Hollywood, CA. In 1994, VNRH began providing community-based HIV prevention services to non-treatment seeking HGMSAs through the VNPD, its prevention division. Contingency management interventions providing positive incentives for behavior change may be particularly well suited for this disenfranchised, high-risk cohort. Specifically, voucher-based incentive therapies (VBRT) may be particularly effective since they have established potency for increasing prosocial behaviors that successfully compete with taking drugs and for reducing drug use. A randomize, controlled trial will assign 144 non-treatment seeking HGMSAs at VNPD to either VBRT or control groups (72/group) for 24 weeks, with planned follow up at 7, 9 and 12 months from randomization. The VBRT group will earn vouchers in exchange for completing prosocial and healthy behaviors and/or submitting drug-negative urine and alcohol-negative breath samples. Vouchers will be redeemable for goods located in an onsite voucher store. The control group will receive feedback regarding behaviors performed and urinalysis and breath alcohol tests, but will not receive voucher points for these behaviors. We will assess the efficacy of the VBRT intervention for increasing prosocial and healthy behavior and reducing substance abuse among these non-treatment seeking HGMSAs receiving services at VNPD. We will also assess the impact of VBRT on other measures of therapeutic change consistent with a harm reduction approach, including reduction of psychiatric symptoms, decreased injection drug use and high-risk sexual behavior, increased participation in prevention programming, improvement in different domains of overall functioning (medical/social/vocational), and increased readiness to change. Additionally, we will examine whether baseline participant characteristics predict VBRT outcomes. Applying VBRT to non-treatment seeking HGMSAs as well as integrating VBRT into a well-established prevention program with a harm reduction philosophy are both highly innovative. Our reinforcement contingencies will also shape behavioral steps towards more complex behaviors, employing a basic operant tenet that has not received sufficient attention. Overall, our proposed research has the potential to have a significant impact on the public health of the Los Angeles homeless, gay and bisexual community. If VBRT is efficacious for motivating non-treatment seeking HGMSAs in a community-based prevention program to increase prosocial and healthy behaviors and decrease drug/alcohol use, established prevention programs may modify their approaches to include contingency management, and use it to address the staggering public health problems HGMSAs face on a daily basis.