Incidence of HIV infection in a New York City methadone maintenance treatment program

Inability to access addiction treatment and risk of HIV infection among injection drug users recruited from a supervised injection facility

BACKGROUND

Treatment for drug addiction is effective in reducing the harms of injection drug use, including infection with HIV and/or hepatitis C. We sought to examine the prevalence and correlates of being unable to access addiction treatment in a representative sample of injection drug users randomly recruited from a supervised injection facility.

METHODS

Using generalized estimating equations, we determined the prevalence and factors associated with being unable to access addiction treatment.

RESULTS

Between 1 July 2004 and 30 June 2006, 889 individuals completed at least one interview and were included in this analysis. At each interview, approximately 20% of respondents reported trying but being unable to access any type of drug or alcohol treatment in the previous 6 months. Being unable to access treatment was independently associated with recent incarceration, daily use of heroin and borrowing used syringes. In a secondary question, the majority of individuals reported waiting lists were the reason for being unable to access treatment.

CONCLUSION

Given the independent association between inability to access addiction treatment and elevated HIV risk behavior, these results suggest expanding addiction treatment may contribute significantly to HIV prevention efforts in this population.

Human immunodeficiency virus prevention and the potential of drug abuse treatment

Since first recognition of the scope of the acquired immunodeficiency syndrome epidemic among the drug-using community, substance abuse treatment has been viewed as playing an important role in preventing new infections. In the past 20 years, many studies have documented significantly lower rates of drug use, drug-related risk behaviors, and human immunodeficiency virus (HIV) infections among drug users who remain in treatment programs. There is also growing evidence that drug detoxification alone is insufficient to provide protection from HIV infection. These findings have important implications for users of cocaine and noninjection drugs, as well as heroin injectors. Despite strong evidence of effectiveness and widespread support for the important public health role of drug treatment, its impact has been compromised by limited availability and acceptability. The available data clearly establish drug abuse treatment as HIV prevention, yet without expansion of existing treatment programs and the continued development of treatments for addiction to cocaine and other widely used stimulants, its public health potential cannot be realized.

HIV incidence in the United States, 1978-1999

CONTEXT

HIV incidence measurements, which reflect recent or current transmission, are valuable for monitoring the epidemic and evaluating prevention programs.

OBJECTIVES

To summarize HIV incidence patterns and trends in U.S. population groups.

DATA SOURCES

Publications in English from 1980 through mid-2000. STUDY SELECTION AND STATISTICAL METHODS: We searched the literature for reports of HIV incidence in the United States. Locally weighted scatterplot smoothing was used to generate smooth curves to estimate trends in incidence. Spearman rank correlation was used to estimate the correlation coefficient between prevalence and incidence.

DATA SYNTHESIS

In 74 eligible reports, HIV incidence varied widely (0.002-19.8 per 100 person-years [py]) depending on risk group. Among men who have sex with men (MSM), HIV incidence peaked in the early 1980s (5-20/100 py) and then declined but remained high during the 1990s (2-4/100 py). Among injection drug users (IDUs), incidence decreased since the mid-1980s but differed by geographic area; in the 1990s, incidence remained high in the East (1-3/100 py) but was lower in the West (<0.5/100 py). Throughout the late 1980s and 1990s, incidence was low and stable in broader populations (blood donors: <0.01/100 py; military personnel: 0.01-0.07/100 py). The correlation between HIV incidence and prevalence was strong in populations with a prevalence less than 1% (r = 0.94, p<.0001), moderate in populations with a prevalence from 1% to less than 10% (r = 0.57, p<.0001), and weak in populations with a prevalence at least 10% (r = 0.23, p=.09).

CONCLUSIONS

HIV prevention in the United States should continue to focus on MSM and IDUs. HIV incidence measurements should be considered for monitoring HIV transmission in MSM, IDUs, and other populations in which seroprevalence is high.

History and current status of opioid maintenance treatments: blending conference session

Opiate addiction is a chronic, relapsing disorder. Left untreated, high morbidity and mortality rates are seen. Pharmacotherapies for this disorder using mu opiate agonists (methadone and levomethadyl acetate) and partial agonists have been developed in the last 40 years. Agonist pharmacotherapy with oral methadone for the treatment of opiate dependence was developed in clinical pharmacology studies at Rockefeller University by Dole, Nyswander, and Kreek. Further studies by this laboratory and others established that moderate to high dose treatment with methadone (80-120 mg) reduced or eliminated opiate use in outpatient settings with consequent reductions in morbidity and up to 4-fold reductions in mortality. Levomethadyl acetate (LAAM), a congener of methadone, is biotransformed to active metabolites responsible for its longer duration of action. The Federal Regulations regarding the dispensation of methadone and LAAM have recently been revised to facilitate the treatment of patients under a "medical maintenance" model. Future regulatory reform will likely involve the establishment of rules for "office based opioid treatment."

Incidence of HIV among injection drug users entering drug treatment programs in four US cities

We estimated seroincidence of human immunodeficiency virus (HIV) and prevalence of risk behaviors among injection drug users (IDUs) who accepted voluntary HIV testing on entry to drug treatment. Record-based incidence studies were conducted in 12 drug treatment programs in New York City (n = 890); Newark, New Jersey (n = 521); Seattle, Washington (n = 1,256); and Los Angeles, California (n = 733). Records of confidential HIV tests were abstracted for information on demographics, drug use, and HIV test results. More detailed data on risk behaviors were obtained by a standardized questionnaire. Although overall incidence rates were relatively low in this population (<1/100 person-years), there was a high prevalence of risk behaviors. Needle sharing was reported by more than one-third of the participants in each of the cities. HIV seroincidence rates were up to three-fold higher among younger ID Us. We found that HIV continued to be transmitted among ID Us who had received both drug treatment and HIV counseling and testing. HIV/AIDS (acquired immunodeficiency syndrome) prevention education should continue to be an important component of drug treatment.

Declining seroprevalence in a very large HIV epidemic: injecting drug users in New York City, 1991 to 1996

OBJECTIVES

This study assessed recent trends in HIV seroprevalence among injecting drug users in New York City.

METHODS

We analyzed temporal trends in HIV seroprevalence from 1991 through 1996 in 5 studies of injecting drug users recruited from a detoxification program, a methadone maintenance program, research storefronts in the Lower East Side and Harlem areas, and a citywide network of sexually transmitted disease clinics. A total of 11,334 serum samples were tested.

RESULTS

From 1991 through 1996, HIV seroprevalence declined substantially among subjects in all 5 studies: from 53% to 36% in the detoxification program, from 45% to 29% in the methadone program, from 44% to 22% at the Lower East Side storefront, from 48% to 21% at the Harlem storefront, and from 30% to 21% in the sexually transmitted disease clinics (all P < .002 by chi 2 tests for trend).

CONCLUSIONS

The reductions in HIV seroprevalence seen among injecting drug users in New York City from 1991 through 1996 indicate a new phase in this large HIV epidemic. Potential explanatory factors include the loss of HIV-seropositive individuals through disability and death and lower rates of risk behavior leading to low HIV incidence.