Behavioural change in injecting drug users: evaluation of an HIV/AIDS education programme

A randomized clinical trial evaluating the impact of counselor training and patient feedback on substance use disorder patients' sexual risk behavior

INTRODUCTION

High risk sex-such as sex with multiple partners, condomless sex, or transactional or commercial sex-is a risk factor in individuals with substance use disorders (SUDs). SUD treatment can reduce sexual risk behavior, but interventions to reduce such behavior in this context have not been consistently effective. This study sought to determine if the impact of treatment on sexual risk behavior can be increased.

METHODS

In a nested 2 × 2 factorial repeated measures design, we examined outcomes of two interventions: training for counselors in talking to patients about sexual risk; and availability to both counselors and patients of a personalized feedback report based on patient self-report of sexual behavior. Counselors received either a brief, information-based, Basic Training, or a multi-session, skills-based Enhanced Training. Their patients completed an audio-assisted computerized assessment of sexual behavior and received either No Feedback or a Personalized Feedback Report (PFR). Four hundred seventy six patients participated. Patient follow-up occurred 3- and 6-months postbaseline. Primary patient outcome measures were Number of Unsafe Sex Occasions (USO) and whether patients reported talking about sex in counseling sessions (Discussed Sex), both in the past 90 days. Secondary outcomes included Number of Sexual Partners, Sex Under the Influence of Substances, and Perceived Condom Barriers.

RESULTS

Patients of Enhanced-condition counselors compared to those of Basic-condition counselors were more likely to report talking about sex with their counselor at 6-month follow-up. Personalized feedback also increased the likelihood of reporting counselor discussions at 6-month follow-up. Neither the training nor the feedback condition affected USO, Number of Partners, or Sex Under the Influence.

DISCUSSION

We discuss why these two interventions apparently altered counselor-patient communication about sexual risk behavior without affecting the behavior itself.

Effect of health education on willingness to undergo HIV screening among antenatal attendees in a teaching hospital in north central Nigeria

BACKGROUND

Testing for HIV during pregnancy provides a useful opportunity to institute treatment for HIV as required as well as protect the unborn baby. The aim of this study was to evaluate the effect of health education on the willingness of antenatal attendees to be screened for HIV.

METHODS

This was a quasiexperimental study involving the sequential enrolment of 122 pregnant women attending antenatal care who were at a gestational age of between 13 and 28 weeks for the study group and subsequent enrolment of the same one month after for the control. Two-stage analysis was done with the use of descriptive statistics and bivariate analysis. Level of significance was set at 5%.

RESULTS

Mean age of the study respondents was 27.6 ± 4.6 years while that of the control was 27.5 ± 4.8 years. Majority of the respondents were married in both study, 88 (72.7%), and control groups 84 (72.4%), 76.1% of the study group and 79.3% of the control group had at least secondary education, and 39.7% of the study group and 37.9% of the control group were primigravidae. Before intervention, 88.4% of the study group and 88.8% of the control group were willing to undergo voluntary HIV screening. There was an increase in this number after intervention (P < 0.05). Age, education, occupation, marital status, and parity were not significantly associated with a willingness to be screened for HIV before and after intervention among the study or control groups.

CONCLUSION

Health education as a strategy to enhance voluntary counseling and testing uptake in antenatal settings is advocated.

Oral substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with Human Immunodeficiency Virus (HIV) and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on risk behaviours and rates of HIV infections

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO to May 2011. We also searched reference lists of articles, reviews and conference abstracts

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two authors independently assessed each study for inclusion

DATA COLLECTION AND ANALYSIS

Two authors independently extracted key information from each of the included studies. Any differences were resolved by discussion or by referral to a third author.

MAIN RESULTS

Thirty-eight studies, involving some 12,400 participants, were included. The majority were descriptive studies, or randomisation processes did not relate to the data extracted, and most studies were judged to be at high risk of bias. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users with methadone or buprenorphine is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. However, because of the high risk of bias and variability in several aspects of the studies, combined totals were not calculated.

AUTHORS' CONCLUSIONS

Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

Substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour.

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on rates of HIV infections, and high risk behaviours.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO to March 2007. We also searched reference lists of articles, reviews and conference abstracts

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two reviewers independently assessed studies for inclusion.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data from included studies, assessed quality and confirmed decisions by consulting with all other reviewers.

MAIN RESULTS

Thirty-three studies, involving 10,400 participants, were included. The majority were not randomised controlled studies and there were problems of confounding and bias. The studies varied in several aspects limiting the extent of quantitative analysis. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection.

AUTHORS' CONCLUSIONS

Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

A test of major assumptions about behavior change: a comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic

This meta-analysis tested the major theoretical assumptions about behavior change by examining the outcomes and mediating mechanisms of different preventive strategies in a sample of 354 HIV-prevention interventions and 99 control groups, spanning the past 17 years. There were 2 main conclusions from this extensive review. First, the most effective interventions were those that contained attitudinal arguments, educational information, behavioral skills arguments, and behavioral skills training, whereas the least effective ones were those that attempted to induce fear of HIV. Second, the impact of the interventions and the different strategies behind them was contingent on the gender, age, ethnicity, risk group, and past condom use of the target audience in ways that illuminate the direction of future preventive efforts.

Factors associated with methadone maintenance therapy use among a cohort of polysubstance using injection drug users in Vancouver

We identified methadone maintenance therapy (MMT) use during follow-up interviews and examined associations between MMT use and socio-demographic and drug-related variables using generalized estimating equations (GEE). Of the 1587 participants recruited into this cohort, 170 (11%) were enrolled in MMT at baseline and additional 498 (31%) initiated MMT during follow-up. Of those ever enrolled in MMT, 406 (61%) ceased MMT and re-initiated MMT on more than one occasion. The median treatment duration was 14.4 months. Factors that were negatively and significantly associated with MMT use in multivariate analyses included: Aboriginal ethnicity (adjusted odds ratio [AOR] = 0.40); recent incarceration (AOR = 0.79); sex trade involvement (AOR = 0.87); syringe lending (AOR = 0.72); heroin injection (AOR = 0.64), whereas female gender (AOR = 2.47), HIV positivity (AOR = 1.57), and crack cocaine smoking (AOR = 1.23) were positively and significantly associated with being on MMT. Unstable housing, syringe borrowing, non-fatal overdose, cocaine injection, and residence in Vancouver's Downtown Eastside were not associated with MMT use in multivariate analyses. Our study demonstrates high rates of initiation of and retention in MMT among local IDUs. While the use of MMT was associated with reductions in heroin use and HIV risk behavior, barriers to Aboriginal IDUs were evident, and the association with increased crack cocaine use deserves further study.

A test of major assumptions about behavior change: a comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic

This meta-analysis tested the major theoretical assumptions about behavior change by examining the outcomes and mediating mechanisms of different preventive strategies in a sample of 354 HIV-prevention interventions and 99 control groups, spanning the past 17 years. There were 2 main conclusions from this extensive review. First, the most effective interventions were those that contained attitudinal arguments, educational information, behavioral skills arguments, and behavioral skills training, whereas the least effective ones were those that attempted to induce fear of HIV. Second, the impact of the interventions and the different strategies behind them was contingent on the gender, age, ethnicity, risk group, and past condom use of the target audience in ways that illuminate the direction of future preventive efforts.

Acceptance of HIV antibody testing among inpatients and outpatients at a public health hospital: a study of rapid versus standard testing

Patients of unknown HIV status who were admitted to the inpatient unit or who were undergoing evaluation in the outpatient clinic of a public health hospital were randomized to receive either the standard HIV test or a rapid HIV test. Patients ranged from 21-71 years of age, and 71% were male. Eleven percent were Hispanic, 36% black, and 48% Caucasian. 35% were injection drug users (IVDU) and 3% men who have sex with men (MSM). The waiting period for the standard test was 2 weeks, and that for rapid testing was approximately 20 minutes. Patients were provided with a telephone number and told to call and schedule a follow-up appointment to receive their standard test results. We found no statistical difference in the acceptance rates of either testing modality overall or with respect to age or gender. We did find a significantly greater percentage of Hispanic patients accepting rapid testing over standard testing (p = 0.04). The overall acceptance rates of rapid and standard testing were 60% and 41%, respectively. This was far lower than expected, and was due in part to the 40% of patients who refused testing because of their having a previous HIV test. All patients who had received previous testing had tested HIV negative, and we did not discover any new cases of HIV in the 103 patients tested during the study. Of those we tested, 95% of those receiving the rapid test and 43% of those receiving the standard test were informed of their status (p < 0.001). Failure of patients to return for follow-up visits accounts for the low percentage of individuals successfully informed of their standard test results. The study suggests that rapid HIV testing is at least as palatable as standard testing in our population. In addition, a far greater percentage of patients are informed of their status using the rapid HIV test. HIV testing programs at our hospital may not be cost effective as our population appears to have been heavily tested previously. Prior to initiating an HIV testing program within a hospital setting, it is imperative to determine the percentage of patients previously tested for HIV.

Substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour.

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on rates of HIV infections, and high risk behaviours.

SEARCH STRATEGY

Multiple electronic databases were searched. Reference lists of retrieved studies, reviews and conference abstracts were handsearched.

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered.

DATA COLLECTION AND ANALYSIS

Each potentially relevant study was independently assessed by two reviewers. For studies that met the inclusion criteria, key information was extracted by one reviewer and confirmed by consultation between all four reviewers.

MAIN RESULTS

Twenty-eight studies, involving 7900 participants, were included. The majority were not randomised controlled studies. Issues of confounding and bias are discussed. The studies varied in several aspects limiting the extent of quantitative analysis.

REVIEWERS' CONCLUSIONS

Oral substitution treatment for opioid-dependent injecting drug users is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review. However, these findings add to the stronger evidence of effectiveness of substitution treatment on drug use, and treatment retention outcomes shown by other systematic reviews. On this basis, the provision of substitution treatment for opioid dependence in countries with emerging HIV and injecting drug use problems as well as in countries with established populations of injecting drug users should be supported.

Adherence to heroin dependence therapies and human immunodeficiency virus/acquired immunodeficiency syndrome infection rates among drug abusers

Adherence is a primary determinant of treatment effectiveness; thus, poor adherence attenuates optimum clinical benefit. A bibliographic review was conducted to evaluate the impact of adherence to heroin dependence treatment on human immunodeficiency virus (HIV) transmission and to identify interventions proven to be effective in improving adherence. The best adherence rates were achieved by methadone and diacetylmorphine, both of which are comparable in promoting significant reduction in heroin use. Methadone adjusted-dose studies with daily doses ranging from 100 to 200 mg and multiple support interventions achieved the highest adherence rates. Studies of methadone maintenance that examined changes in HIV prevalence of infection have found that higher treatment adherence is correlated with a reduction in HIV transmission. These data suggest that patients who adhere continuously to methadone treatment are less likely to continue injecting illicit drugs and sharing contaminated injection equipment than are those who interrupt treatment, thus preventing the spread of HIV via drug injection.

Recommendations for incorporating human immunodeficiency virus (HIV) prevention into the medical care of persons living with HIV

The estimated number of annual new human immunodeficiency virus (HIV) infections in the United States has remained at 40,000 for >10 years. Reducing the rate of transmission will require new strategies, including emphasis on prevention of transmission by HIV-infected persons. Medical care providers can affect HIV transmission by screening HIV-infected patients for risk behaviors, communicating prevention messages, discussing sexual and drug-use behaviors, reinforcing changes to safer behavior, referring patients for services such as substance abuse treatment, facilitating partner counseling and referral, and identifying and treating other sexually transmitted diseases. The Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) have recently collaborated to develop evidence-based recommendations for incorporating HIV prevention into the medical care of persons living with HIV. This article summarizes key aspects of the recommendations.

Adherence to methadone is associated with a lower level of HIV-related risk behaviors in drug users

There have been limited studies on the potential role of methadone treatment in HIV prevention in Asia. Over an 8-week period, we assessed the profiles of drug-taking and HIV risk behaviors, and tried to identify their relationships with methadone adherence in 690 clients who attended Hong Kong's methadone treatment program. In the preceding month, 71% of respondents reported using drugs and two-thirds of those respondents who had injected drugs at some time in their lives injected then. Infrequent clients who attended methadone clinics <2 times in the previous week were twice more likely to have injected drugs in the last month and six times more likely to have >5 injections in the last week than frequent clinic attendees. Also, clients taking <60 mg methadone daily were twice more likely to have >5 injections in the last week than those taking > or = 60 mg methadone. The findings called for further studies on harm reduction programs for HIV prevention among drug users in Asian countries.

Optimal investment in a portfolio of HIV prevention programs

OBJECTIVES

In this article, the authors determine the optimal allocation of HIV prevention funds and investigate the impact of different allocation methods on health outcomes.

METHODS

The authors present a resource allocation model that can be used to determine the allocation of HIV prevention funds that maximizes quality-adjusted life years (or life years) gained or HIV infections averted in a population over a specified time horizon. They apply the model to determine the allocation of a limited budget among 3 types of HIV prevention programs in a population of injection drug users and nonusers: needle exchange programs, methadone maintenance treatment, and condom availability programs. For each prevention program, the authors estimate a production function that relates the amount invested to the associated change in risky behavior.

RESULTS

The authors determine the optimal allocation of funds for both objective functions for a high-prevalence population and a low-prevalence population. They also consider the allocation of funds under several common rules of thumb that are used to allocate HIV prevention resources. It is shown that simpler allocation methods (e.g., allocation based on HIV incidence or notions of equity among population groups) may lead to alloctions that do not yield the maximum health benefit.

CONCLUSIONS

The optimal allocation of HIV prevention funds in a population depends on HIV prevalence and incidence, the objective function, the production functions for the prevention programs, and other factors. Consideration of cost, equity, and social and political norms may be important when allocating HIV prevention funds. The model presented in this article can help decision makers determine the health consequences of different allocations of funds.

HIV transmission and the cost-effectiveness of methadone maintenance

OBJECTIVES

This study determined the cost-effectiveness of expanding methadone maintenance treatment for heroin addiction, particularly its effect on the HIV epidemic.

METHODS

We developed a dynamic epidemic model to study the effects of increased methadone maintenance capacity on health care costs and survival, measured as quality-adjusted life-years (QALYs). We considered communities with HIV prevalence among injection drug users of 5% and 40%.

RESULTS

Additional methadone maintenance capacity costs $8200 per QALY gained in the high-prevalence community and $10,900 per QALY gained in the low-prevalence community. More than half of the benefits are gained by individuals who do not inject drugs. Even if the benefits realized by treated and untreated injection drug users are ignored, methadone maintenance expansion costs between $14,100 and $15,200 per QALY gained. Additional capacity remains cost-effective even if it is twice as expensive and half as effective as current methadone maintenance slots.

CONCLUSIONS

Expansion of methadone maintenance is cost-effective on the basis of commonly accepted criteria for medical interventions. Barriers to methadone maintenance deny injection drug users access to a cost-effective intervention that generates significant health benefits for the general population.

Social network characteristics as mediators in the relationship between sexual abuse and HIV risk

Recent research suggests that sexual abuse may be a potent risk factor for engaging in HIV risk behaviors for women. This relationship is likely mediated by the long term sequelae of sexual abuse. One plausible causal pathway posits that specific social network characteristics increase HIV risk exposure opportunities. This is premised on the belief that previous sexual abuse predisposes some women to become members of risk networks characterized by deviant behaviors and that HIV risk occurs in the context of these networks. One hundred and thirty women opiate users were systematically recruited from methadone maintenance and syringe exchange programs in New York City. The women participated in a one hour interview and provided information on drug use and frequency, HIV drug and sex risk behaviors, social network characteristics, and sexual abuse histories. Univariate and logistic regression techniques were used to test the relationship between sexual abuse and increased HIV risk as mediated by social network characteristics. Previous sexual abuse was strongly related to all social network characteristics examined. Moreover, these network characteristics appeared to affect patterns of drug use in identifiable ways. Social isolation was the only network characteristic associated with both HIV drug and sex risk behaviors. However, although a history of sexual abuse was significantly associated with five of the seven specific HIV risk behaviors examined, the relationship between sexual abuse and HIV risk behaviors remained unchanged when social network characteristics were included in the statistical model. Overall, the results suggest that a sexual abuse experience or its aftermath influence behavior far into the future. However, the results of this study did not show social network characteristics mediating the relationship between sexual abuse and HIV risk. Rather, previous sexual abuse and social network characteristics appear to be independent contributors to HIV risk behaviors for women.

Effectiveness of HIV interventions among women drug users

A prospective cohort study was conducted among chronic injecting and crack cocaine drug using women. The hypothesis tested was that participation in a standard-plus-innovative intervention was more likely to produce behavior change than participation in a standard intervention. Standardized intervention protocols and corresponding instruments were designed. Data were collected on drug and sex risk behaviors at baseline and six-month follow-up intervals. The level of behavioral change in two intervention arms--standard and a standard-plus-innovative intervention--was measured by composite sex risk and drug risk scores using the generalized estimating equation approach. The results show that on four risk measures the enhanced intervention was significantly associated with positive change in both drug use and sexual behavior: less frequent drug use, less drug use during sex, and more frequent condom use during particular frequencies for specific types of sexual activities. Public health interventions are effective when targeting specific risk behaviors through interventions tailored to prevent HIV and reduce risk behaviors among specific cultural and gender groups.

HIV antibody seroprevalence and associated risk factors in sex workers, drug users, and prisoners in Sindh, Pakistan

OBJECTIVE

To determine prevalence of HIV infection and risk behaviors in commercial sex workers (CSWs), drug users, and prisoners in Sindh, Pakistan.

METHODS

A medical clinic was established in a "red-light" district of Karachi. Eighty-one CSWs who registered at the clinic between November 1993 and June 1994 were provided HIV counseling and testing and administered a risk factor questionnaire. Next, 316 male drug users were tested for HIV-1 antibody from April to July 1994. Finally, a voluntary serosurvey of HIV-1 and HIV-2 and risk behaviors of 3525 prisoners in Sindh was conducted between July 1994 and December 1994. Abbott Recombinant HIV third-generation enzyme-linked immunosorbent assay (ELISA) and confirmatory testing with Western blot analysis were used in all three groups.

RESULTS

None of 81 CSWs tested for HIV-1 antibody were positive. None of 316 drug users tested positive for HIV-1 antibody. Of 3441 male prisoners, 1 was HIV-1 infected, and of 84 female prisoners, 1 was HIV-1 infected. No prisoner was positive for HIV-2 antibody.

DISCUSSION

The prevalence of HIV in CSWs, drug users, and prisoners in Sindh is low at present. Intervention programs implemented at this stage can make an impact in HIV prevention.

Conduct disorder and HIV risk behaviors among runaway and homeless adolescents

This study was designed to assess the prevalence of conduct disorder (CD) among runaway and homeless adolescents and to investigate associations between CD and HIV risk behaviors. The Diagnostic Interview Schedule for Children and a standardized HIV risk assessment questionnaire were administered to 219 runaway and homeless adolescents recruited from a drop-in center serving high-risk youth. One-half of the males and 60% of the females were diagnosed with CD. In multivariate analyses, CD was the strongest predictor of lifetime use of heroin and/or cocaine and exchanging sex for money, drugs, food or shelter, as well as the number of drugs used and the number of sex partners in the 3 months preceding the interview. The high rate of CD in this population, and the association between CD and both drug and sex-related HIV risk behaviors, indicate a need for interventions that consider the influence of this psychiatric diagnosis on high-risk behaviors.

Methadone maintenance and the likelihood of risky needle-sharing

Survey data were used to study the association of methadone maintenance and needle-sharing. An ordinal scale of HIV risk was derived from the number of persons from whom subjects reported accepting a used needle and syringe in the 6 months prior to interview. The odds of respondents in methadone maintenance being in the higher risk group were half those of daily heroin users not in treatment for all three transitions in a four-level ordinal scale of risk (OR 0.55, 95% CL 0.33 to 0.90, ordinal logistic regression). This association disappeared when methadone patients who had not injected in the month prior to interview were excluded from the analysis. Subjects' knowledge concerning HIV and AIDS had no measurable association with the outcome. It is concluded that methadone maintenance reduces heroin addicts' risk of infection with HIV by reducing the likelihood of their injecting drugs rather than by changing their injecting behavior.

AIDS related information, attitudes and behaviours among Italian male young people

In order to evaluate the AIDS related sources of information, knowledge, attitudes and behaviours among male young people it was filled in a multi-choice anonymous questionnaire by 2018 subjects, called for the first medical examination to Italian Navy and by 1348 recruits. The data from the latter group were used to make comparisons with our previous survey carried out in 1988. The most important sources of information on AIDS were mass media and school, on sexuality friends and family. AIDS awareness was greater among the high educated subjects and positively influenced by mass media and school as sources of information. In agreement with these data, knowledge was better about AIDS than about sexuality. Risk perception was positively influenced by the AIDS-related knowledge for called youth and a greater intolerance towards infected people was observed among the less educated and the less AIDS-aware subjects. On average 46% of the called up young men and 74% of recruits declared to be sexually active: among these, the mean age at the first sexual intercourse was 16, over 60% declared to have had multiple partners, over 30% unknown partners and over 30% didn't use condoms; 20% of called up and 38% of recruits indicated 2 or 3 risk behaviours. Factors determining sex-related risks were different according to the behaviour and the considered group. These results suggest that it is important for young people to be well informed about sex and AIDS before the beginning of sexual activity, if possible during compulsory school.

Methadone treatment as a determinant of HIV risk reduction among injecting drug users: a nested case-control study

In order to evaluate the protective effect of methadone treatment on HIV infection, we performed a nested case-control study on seroconverters (cases) who were part of a cohort of HIV-negative injecting drug users (IDUs) (controls). Controls were matched with cases by sex, age, duration of drug use and follow-up time. Information on methadone treatment in the year prior to seroconversion was collected using clinical registries. Univariate and multivariate conditional logistic regression were used to identify variables related to HIV-seroconversion. The study included 40 cases and 40 controls. Univariate analysis showed the following variables to be associated to HIV seroconversion: number of cycles of treatment, daily dose and time out of treatment. After performing multivariate analysis, daily dose remained protective with a linear effect noted even at low doses and time out of treatment was the most important risk factor. The risk increased 1.5 times for every 3 months spent out of treatment. Long-term methadone treatment protects against HIV infection. Its effect may be attributable to a reduction in the frequency of injecting drug use or to an increased knowledge of risk factors following counselling in drug centres.

Evaluation of a training course on sexual counselling in a drug work setting

It has been repeatedly reported that while risks associated with the injecting behaviour of drug users has been reduced, no parallel changes have been made in sexual risk behaviour. Counselling advice to clients attending drug unit services has not focused sufficiently on the sexual behaviour of this client group. The present study evaluates the impact of a 4-day tailored training course on the counselling practices of two teams of drug workers at a London hospital. The course was designed following the experience and evaluation of a more general training course on sexual issues, and included information, group discussions, experiential learning and skills training. Results indicate that though there were no significant behavioural changes, some attitudinal changes have taken place; training appears to have increased the staff's awareness of the importance of sexual counselling and reduced the perceived difficulty of discussing certain specific sexual issues. The implications of single-agency training courses are discussed and recommendations are made for future training courses on the basis of the findings of this study.

HIV-transmission knowledge in drug users from outpatient facilities in Spain. A national survey

Knowledge of AIDS and its transmission was studied in patients undergoing drug-dependence treatment for opiates and/or cocaine. The study area included all of Spain and was carried out via a questionnaire assessing information about risk practices, HIV serostatus, etc, and 13 true or false questions concerning HIV-transmission knowledge. The main purpose of the present study was to analyse the relationship between the level of information found in patients and factors potentially related to it, including the practice of high-risk activities for HIV transmission, the sources of information and behaviour modification. Findings indicate that poor information was associated with the use of non-sterile needles, anal-penis sexual relations, non-use of condoms, lack of preventive measures in daily cohabitation, and lack of previous drug-dependence treatment. Determining factors of being well-informed were a high level of education, a longer duration of intravenous drug use, and contact with the Health Service as a source of information. These findings partially support the need to implement programs aimed at improving knowledge about HIV in the population of drug users.