A randomized controlled trial of Structural Ecosystems Therapy for HIV medication adherence and substance abuse relapse prevention

Abstract

Background: Substance abuse in women with HIV/AIDS overshadows other priorities, including health care. Substance abuse may cause women to avoid health care systems and not adhere to their medication regimen.

Methods: A randomized controlled trial tested the efficacy of Structural Ecosystems Therapy (SET) relative to a psychoeducational Health Group (HG) in 126 HIV+ women in recovery. SET, a 4-month intervention, focused on building family support for relapse prevention and HIV medication adherence. Over 12-month follow-up, women were assessed for drug use and medication adherence every 2 months; CD4 T-cell count and HIV viral load were assessed every 4 months.

Results: Levels of drug use did not differ by condition. There was a significant difference in curvature of the rates of change in drug use with SET increasing and then decreasing and HG decreasing and then increasing. Women in SET were more likely to increase substance abuse services in response to relapse and separate from drug using household members than were women in HG. These two changes explained the decline in drug use observed within SET between 6 and 12 months. SET showed declines in medication adherence but increases in CD4 T-cell count relative to HG. The increase in CD4 T-cell count in SET was related to increasing proportions of women in SET taking antiretroviral medications.

Conclusion: The results of the trial were mixed. Women in SET did not show better drug use or medication adherence outcomes, but did show improvement in CD4 T-cell count and theoretical mechanisms of action on drug relapse.

Figure 1

CONSORT Subject Flow Diagram

Figure 2

Estimated trajectories of substance use days, the proportion of medication adherence, and CD4-Cell count for women in SET and the Health Group.

Figure 3

Estimated trajectories of family dissatisfaction, the probability of living with a substance user, and drug treatment visits for women in SET and the Health Group.

Figure 4

Mediation of SET's decrease in substance use days by engagement with treatment services. Note: only significant standardized pathways are shown; pathways from prior substance use to later substance use treatment were not statistically significant.

Figure 5

Moderation of estimated substance use days by initially living with a substance user for women in SET and the Health Group.