Integrating HIV and Stimulant-Use Disorder Treatment: A Pilot Implementation Effectiveness Trial of Contingency Management in HIV Care

BACKGROUND: Stimulants, including cocaine and methamphetamine, are associated with HIV transmission and viremia. Contingency management (CM), which provides financial incentives for nonreactive urine testing, is first-line treatment for stimulant-use disorder (StUD), yet has been minimally studied or integrated into HIV care. METHODS: We conducted a 12-week, single-arm, implementation-effectiveness pilot of weekly CM in a safety-net HIV clinic for persons with HIV (PWH) who have StUD. Participants received escalating incentives for stimulant-negative and/or tenofovir-reactive point-of-care urine assays. Using the RE-AIM framework, we evaluated Reach (demographics, attendance), Effectiveness (stimulant-negative/tenofovir-positive tests, HIV virologic suppression [VS]), and Implementation. We conducted semi-structured, in-depth participant interviews following intervention completion to explore perceived impact and implementation. RESULTS: From September 2023 to February 2024, we enrolled 31 PWH with StUD: 77% used methamphetamine, 35% cocaine, and 19% fentanyl. Only 17 of 31 (55%) had VS at baseline. Participants attended a mean of 5 of 12 visits (42%). Among PWH who attended postenrollment visits (26/31), 61 of 110 (56%) stimulant tests were negative and 98% (89/91) of tenofovir tests were positive. Postintervention, 88% (23/26) of retained participants achieved VS (P < .01). Qualitative interviews revealed factors enhancing Reach (embedding CM within HIV care), Effectiveness (incentives supporting adherence self-efficacy; program providing structure and motivation), and Implementation (supportive staff relationships, nonjudgmental approach). CONCLUSIONS: Contingency management for stimulant use and/or antiretroviral therapy adherence (using point-of-care tenofovir assays) embedded into HIV care was associated with reduced stimulant use and gains in viral suppression. Scalability of integrating HIV and StUD management using CM merits further evaluation. Clinical Trials Registration. clinicaltrials.gov (NCT06564792).