Voucher-Based Incentives in a Prevention Setting

Homelessness is a significant problem plaguing American cities and homeless substance
abusers face increased risks. Homeless, substance abusing men who have sex with men (MSM)
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 homeless substance-abusing MSMs in Hollywood, CA. In 1994, VNRH began providing
community-based HIV prevention services to non-treatment seeking homeless substance-abusing
MSMs 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
randomized, controlled trial will assign 144 non-treatment seeking homeless
substance-abusing MSMs 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 homeless substance-abusing MSMs 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 homeless
substance-abusing MSMs 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 homeless substance-abusing MSMs 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.

Inclusion Criteria:

- Self-identified, non-treatment seeking, men who have sex with men (MSM) at least 18
years of age and eligible to participate in the VNPD Men's Program. To be eligible
to participate in the VNPD Men's Program, a person must report that they have sex
with men (or men and women) and actively use drugs or alcohol.

- DSM-IV diagnosis of substance dependence as determined by structured clinical
interview for DSM-IV (SCID) on at least one of the following substances: alcohol,
marijuana, methamphetamine, cocaine, crack, MDMA (ecstasy), opiates, or dissociative
anesthetics (PCP, ketamine). These substances were chosen because they are the ones
commonly used by individuals contacted by the VNPD's street outreach workers.

- Ability to understand and provide written informed consent. Also see section D6.1 for
consent procedures used with vulnerable populations.

- Able to provide sufficient locator information for follow-up and/or known to VNPD
outreach workers.

Exclusion Criteria: