Reducing Drug Use and HIV Risk in Drug-dependent Adults Arrested for Prostitution

The combination of using injection drugs, smoking crack cocaine, having multiple sex
partners, and inconsistent condom use results in substantial risk for acquiring and
transmitting HIV, and many drug dependent adults who have been arrested on charges of
prostitution fit this profile. Existing interventions for reducing HIV risk have had limited
efficacy in drug-dependent sex workers, and criminal justice approaches have been
ineffective despite their high cost. A potentially ideal alternative is to divert
drug-dependent arrestees from prosecution to a treatment that reduces drug use and HIV sex
risk behaviors, while providing job skills training and promoting community employment to
alleviate the financial need to continue sex work. In order to provide an effective
therapeutic alternative to criminal prosecution, the investigators propose to develop a
multifaceted intervention that includes opiate agonist treatment (i.e., methadone OR
buprenorphine) and the Therapeutic Workplace. The Therapeutic Workplace is a supported
environment in which participants are required to provide drug-free urine samples to access
paid job skills training or employment and to maintain the maximum rate of pay. The overall
intervention is designed to reduce drug use and HIV risk behaviors, and simultaneously
promote employment. The proposed project is a 2-year Stage I behavior therapy development
effort that will include the development, manualization and pilot testing of a Therapeutic
Workplace intervention tailored to drug-dependent adults arrested for prostitution. In the
pilot study, the investigators will recruit opiate- and cocaine-dependent adults arrested
for prostitution from the Eastside District Court in Baltimore. Eligible individuals will be
offered methadone treatment in lieu of prosecution and will be required to remain in
methadone treatment for 90 days to have the charges against them dropped. After enrolling in
opiate agonist treatment, the diverted individuals will be invited to participate in the
pilot study. Interested individuals will be randomly assigned to receive the standard opiate
agonist treatment services or these services plus the Therapeutic Workplace. The Therapeutic
Workplace has two phases. In Phase 1, participants will be offered four months of
stipend-supported job training in the Therapeutic Workplace. In Phase 2, participants will
be encouraged to seek employment in a community job and will receive wage subsidies for four
months for maintaining community employment or engaging in supervised job seeking.
Throughout both phases, participants will be required to provide drug-free urine samples to
receive Therapeutic Workplace wages (training stipends in Phase 1 and wage subsidies in
Phase 2). The wage subsidy program will include drug testing managed by a national supplier
of drug-free workplace services. Overall, this treatment could serve as a novel and ideal
intervention for drug-dependent adults arrested for prostitution while reducing criminal
justice costs.