HIV seroconversion in intravenous drug users in San Francisco, 1985-1990

An outbreak of HIV infection among people who inject drugs linked to injection of propofol in Taiwan

INTRODUCTION

The aim of this study was to report an HIV outbreak related to propofol-injection and the impact of regulating propofol on the HIV epidemic among people who inject drugs (PWID).

METHODS

A retrospective cohort study of 252 PWID who were diagnosed with an HIV infection between 2014 and 2017 in Taiwan. The propofol information was collected by routine epidemic surveillance and interviews. We linked several national databases to collect other related factors, including methadone maintenance treatment (MMT) attendance and incarceration. The serums were tested for recent infection by the LAg-avidity EIA assay and relationship of the trains by the Phylogenetic tree analysis. Analyses were conducted using the R Surveillance package for retrospective modeling for outbreak detection. A multiple logistic regression was used to evaluate the association between propofol-injection and other related factors.

RESULTS

There were 28 cases reported with propofol-injection, all of which were reported in Central Taiwan. A total of 11 (50%) cases among 22 propofol-injectors with serums were recent infections, which were higher than that 33 (23.4%) of non-propofol group. The phylogenetic tree indicated that 6 propofol-injectors were grouped together with the same cluster in circular. The HIV epidemic curve among PWID revealed an outbreak of 82 in 2015, which then decreased to 43 in 2016 after propofol began to be regulated as a Schedule 4 controlled drug in August 2015. In a multiple logistic regression, attendance at methadone clinics was associated with a significantly higher risk for propofol-injection (adjusted OR = 2.43, 95% CI = 0.98-5.98), and HIV reported in the year 2015 was associated with an increased risk of propofol-injection (adjusted OR = 4, 95% CI = 1.08-14.86).

CONCLUSIONS

Our data indicate that the government regulation of propofol as a controlled drug strategy was associated with significant reduction in the spread of HIV among PWID.

Measures of human immunodeficiency virus (HIV) community viral load and HIV incidence among people who inject drugs

PURPOSE

To evaluate the measures of community human immunodeficiency virus (HIV) viral load (VL) and the association with HIV incidence among people who inject drugs (PWID).

METHODS

Data were from 1986 to 1999 Urban Health Study conducted among PWID in the San Francisco Bay Area. Extant measures of community VL use mean VL among HIV + study participants, not accounting for the proportion of HIV- individuals. We compared the strength of the associations between HIV incidence and the traditionally measured mean community VL and a new prevalence-adjusted community VL, calculated by dividing the sum of VL among HIV + participants by the total participants irrespective of HIV status.

RESULTS

Mean community VL was not correlated with HIV incidence in this sample of PWID (rs = 0.32, P = .28). However, prevalence-adjusted community VL was strongly correlated with HIV incidence (rs = 0.69, P = .009). Nested complimentary log-log linear models indicated that increases in community VL and prevalence-adjusted community VL were both associated with HIV incidence, but prevalence-adjusted community VL was a more sensitive measure (hazard ratio = 1.28, P = .038 and hazard ratio = 3.29, P < .001, respectively).

CONCLUSIONS

The effect of community VL on HIV incidence may be stronger than previously reported. Future studies of community VL surveillance should consider accounting for the prevalence of HIV using a prevalence-adjusted community VL measure.

Effect of low-threshold methadone maintenance therapy for people who inject drugs on HIV incidence in Vancouver, BC, Canada: an observational cohort study

BACKGROUND

HIV infection in people who inject drugs (PWID) is an international public health concern. We aimed to assess the effect of methadone maintenance therapy on HIV incidence in PWID in Vancouver, BC, Canada, where methadone is widely available through family physicians' offices and dispensed by community pharmacies.

METHODS

Data were derived from the Vancouver Injection Drug Users Study (VIDUS), a prospective cohort of PWID in Vancouver. Individuals were eligible to enrol in VIDUS if they had injected illicit drugs at least once in the previous month and lived in the Greater Vancouver region. Participants responded to an interviewer-administered questionnaire and provided blood samples at enrolment and follow-up visits every 6 months. We estimated time to HIV seroconversion with Kaplan-Meier methods and used Cox proportional hazards methods to assess associations between methadone use and time to seroconversion.

FINDINGS

1639 HIV-negative individuals were recruited between May 1, 1996, and May 31, 2013. Of these individuals, 138 had HIV seroconversion during a median of 75·5 months (IQR 33·4-115·3) of follow-up. In multivariate Cox regression analyses, methadone maintenance therapy remained independently associated with a reduced hazard of HIV infection after adjustment for sociodemographic characteristics and drug use patterns (adjusted relative hazard 0·64, 95% CI 0·41-0·98).

INTERPRETATION

Methadone maintenance therapy for PWID made available through primary care physicians and community pharmacies can help to achieve public health goals such as reducing the spread of HIV.

FUNDING

US National Institutes of Health, Canada Research Chair, Canadian Institutes of Health Research.

Methadone maintenance therapy and HIV counseling and testing are associated with lower frequency of risky behaviors among injection drug users in China

Three consecutive cross-sectional surveys were conducted among injection drug users (IDUs). Of 2,530 participants, 47.7% reported ever sharing needles, 78.2% having had unprotected sex in the last month, 34.4% not receiving either methadone maintenance therapy (MMT) or HIV voluntary counseling and testing (VCT), 4.8% ever receiving MMT-only, 36.6% ever receiving VCT-only, and 24.2% ever receiving both MMT and VCT. MMT-only and the combination of MMT and VCT had significant associations with needle sharing and on unprotected sexual behaviors. Effectively integrating VCT into MMT services is a logical way to maximize the impact of both interventions on risky behaviors among IDUs.

HIV risk reduction with buprenorphine-naloxone or methadone: findings from a randomized trial

OBJECTIVES

Compare HIV injecting and sex risk in patients being treated with methadone (MET) or buprenorphine-naloxone (BUP).

METHODS

Secondary analysis from a study of liver enzyme changes in patients randomized to MET or BUP who completed 24 weeks of treatment and had 4 or more blood draws. The initial 1:1 randomization was changed to 2:1 (BUP:MET) after 18 months due to higher dropout in BUP. The Risk Behavior Survey measured HIV risk before 30 days at baseline and weeks 12 and 24.

RESULTS

Among 529 patients randomized to MET, 391 (74%) were completers; among 740 randomized to BUP, 340 (46%) were completers; 700 completed the Risk Behavior Survey. There were significant reductions in injecting risk (P < 0.0008) with no differences between groups in mean number of times reported injecting heroin, speedball, other opiates, and number of injections; or percent who shared needles; did not clean shared needles with bleach; shared cookers; or engaged in front/back loading of syringes. The percent having multiple sex partners decreased equally in both groups (P < 0.03). For males on BUP, the sex risk composite increased; for males on MET, the sex risk decreased resulting in significant group differences over time (P < 0.03). For females, there was a significant reduction in sex risk (P < 0.02) with no group differences.

CONCLUSIONS

Among MET and BUP patients who remained in treatment, HIV injecting risk was equally and markedly reduced; however, MET retained more patients. Sex risk was equally and significantly reduced among females in both treatment conditions, but it increased for males on BUP and decreased for males on MET.

Changes in HIV incidence among people who inject drugs in Taiwan following introduction of a harm reduction program: a study of two cohorts

BACKGROUND

Harm reduction strategies for combating HIV epidemics among people who inject drugs (PWID) have been implemented in several countries. However, large-scale studies using sensitive measurements of HIV incidence and intervention exposures in defined cohorts are rare. The aim of this study was to determine the association between harm reduction programs and HIV incidence among PWID.

METHODS AND FINDINGS

The study included two populations. For 3,851 PWID who entered prison between 2004 and 2010 and tested HIV positive upon incarceration, we tested their sera using a BED HIV-1 capture enzyme immunoassay to estimate HIV incidence. Also, we enrolled in a prospective study a cohort of 4,357 individuals who were released from prison via an amnesty on July 16, 2007. We followed them with interviews at intervals of 6-12 mo and by linking several databases. A total of 2,473 participants who were HIV negative in January 2006 had interviews between then and 2010 to evaluate the association between use of harm reduction programs and HIV incidence. We used survival methods with attendance at methadone clinics as a time-varying covariate to measure the association with HIV incidence. We used a Poisson regression model and calculated the HIV incidence rate to evaluate the association between needle/syringe program use and HIV incidence. Among the population of PWID who were imprisoned, the implementation of comprehensive harm reduction programs and a lower mean community HIV viral load were associated with a reduced HIV incidence among PWID. The HIV incidence in this population of PWID decreased from 18.2% in 2005 to 0.3% in 2010. In an individual-level analysis of the amnesty cohort, attendance at methadone clinics was associated with a significantly lower HIV incidence (adjusted hazard ratio: 0.20, 95% CI: 0.06-0.67), and frequent users of needle/syringe program services had lower HIV incidence (0% in high NSP users, 0.5% in non NSP users). In addition, no HIV seroconversions were detected among prison inmates.

CONCLUSIONS

Although our data are affected by participation bias, they strongly suggest that comprehensive harm- reduction services and free treatment were associated with reversal of a rapidly emerging epidemic of HIV among PWID. Please see later in the article for the Editors' Summary.

Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness

BACKGROUND

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

METHODS

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

RESULTS

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission.

CONCLUSION

Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

HIV among people who inject drugs in Central and Eastern Europe and Central Asia: a systematic review with implications for policy

BACKGROUND AND OBJECTIVES

HIV among people who inject drugs (PWID) is a major public health concern in Eastern and Central Europe and Central Asia. HIV transmission in this group is growing and over 27 000 HIV cases were diagnosed among PWID in 2010 alone. The objective of this systematic review was to examine risk factors associated with HIV prevalence among PWID in Central and Eastern Europe and Central Asia and to describe the response to HIV in this population and the policy environments in which they live.

DESIGN

A systematic review of peer-reviewed and grey literature addressing HIV prevalence and risk factors for HIV prevalence among PWID and a synthesis of key resources describing the response to HIV in this population. We used a comprehensive search strategy across multiple electronic databases to collect original research papers addressing HIV prevalence and risk factors among PWID since 2005. We summarised the extent of key harm reduction interventions, and using a simple index of 'enabling' environment described the policy environments in which they are implemented.

STUDIES REVIEWED

Of the 5644 research papers identified from electronic databases and 40 documents collected from our grey literature search, 70 documents provided unique estimates of HIV and 14 provided multivariate risk factors for HIV among PWID.

RESULTS

HIV prevalence varies widely, with generally low or medium (<5%) prevalence in Central Europe and high (>10%) prevalence in Eastern Europe. We found evidence for a number of structural factors associated with HIV including gender, socio-economic position and contact with law enforcement agencies.

CONCLUSIONS

The HIV epidemic among PWID in the region is varied, with the greatest burden generally in Eastern Europe. Data suggest that the current response to HIV among PWID is insufficient, and hindered by multiple environmental barriers including restricted access to services and unsupportive policy or social environments.

Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis

OBJECTIVE

To quantify the effect of opiate substitution treatment in relation to HIV transmission among people who inject drugs.

DESIGN

Systematic review and meta-analysis of prospective published and unpublished observational studies.

DATA SOURCES

Search of Medline, Embase, PsychINFO, and the Cochrane Library from the earliest year to 2011 without language restriction.

REVIEW METHODS

We selected studies that directly assessed the impact of opiate substitution treatment in relation to incidence of HIV and studies that assessed incidence of HIV in people who inject drugs and that might have collected data regarding exposure to opiate substitution treatment but not have reported it. Authors of these studies were contacted. Data were extracted by two reviewers and pooled in a meta-analysis with a random effects model.

RESULTS

Twelve published studies that examined the impact of opiate substitution treatment on HIV transmission met criteria for inclusion, and unpublished data were obtained from three additional studies. All included studies examined methadone maintenance treatment. Data from nine of these studies could be pooled, including 819 incident HIV infections over 23,608 person years of follow-up. Opiate substitution treatment was associated with a 54% reduction in risk of HIV infection among people who inject drugs (rate ratio 0.46, 95% confidence interval 0.32 to 0.67; P<0.001). There was evidence of heterogeneity between studies (I(2)=60%, χ(2)=20.12, P=0.010), which could not be explained by geographical region, site of recruitment, or the provision of incentives. There was weak evidence for greater benefit associated with longer duration of exposure to opiate substitution treatment.

CONCLUSION

Opiate substitution treatment provided as maintenance therapy is associated with a reduction in the risk of HIV infection among people who inject drugs. These findings, however, could reflect comparatively high levels of motivation to change behaviour and reduce injecting risk behaviour among people who inject drugs who are receiving opiate substitution treatment.

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.

Correlates of risky injection practices among past-year injection drug users among the US general population

BACKGROUND

With an estimated 1 million active injection drug users (IDUs), injection drug use continues to be a public health concern in the United States. Risky injection practices have been associated with the transmission of HIV, Hepatitis B and C, as well as other skin and soft tissue infections.

METHODS

We used data from 463 respondents, aged 18 and older, who were past-year IDUs in the 2005-2008 National Survey of Drug Use and Health (NSDUH). We investigated correlates of risky injection behavior among these recent IDUs.

RESULTS

Older age (≥ 35 versus 18-25) was associated with reusing one's own needle at last injection (aOR=1.80 [1.02-3.17], as were past year heroin (aOR=2.59 [1.18-5.66]) and cocaine injection (aOR=2.17 [1.13-4.15]). Past year crack cocaine use was positively associated with not cleaning needles with bleach (aOR=2.18 [1.10-4.33]). Past year cocaine injection was associated with obtaining needles in a risky manner (aOR=2.29 [1.23-4.25]). Methamphetamine injection was associated with obtaining needles in less risky ways (aOR=0.41 [0.20-0.84]).

CONCLUSION

Our findings indicate that some IDUs are continuing to engage in high risk injection behaviors. The identification of potential at-risk populations of IDUs may have implications for harm reduction interventions and HIV prevention programs.

Progress in HIV reduction and prevention among injection and noninjection drug users

Substantial progress has been made in reducing HIV among injection drug users (IDUs) in the United States, despite political and social resistance that reduced resources and restricted access to services. The record for HIV prevention among noninjecting drug users is less developed, although they are more numerous than IDUs. Newer treatments for opiate and alcohol abuse can now be integrated into primary HIV care; treatment for stimulant abuse is less developed. All drug users present challenges for newer HIV prevention strategies (eg, "test and treat," nonoccupational postexposure prophylaxis and preexposure prophylaxis, contingency management, and conditional cash transfer). A comprehensive HIV prevention program that includes multicomponent multilevel approaches (ie, individual, network, structural) has been effective in HIV prevention among IDUs. Expanding these approaches to noninjecting drug users, especially those at highest risk (eg, minority men who have sex with men) and incorporating these newer approaches is a public health priority.

The effectiveness of harm reduction in preventing HIV among injecting drug users

There is now compelling evidence that harm reduction approaches to HIV prevention among injecting drug users are effective, safe and cost-effective. The evidence of effectiveness is strongest for needle and syringe programs and opioid substitution treatment. There is no convincing evidence that needle and syringe programs increase injecting drug use. The low prevalence approximately 1%) of HIV among injecting drug users reflects the early adoption and rapid expansion of harm reduction in Australia. Countries that have provided extensive needle and syringe programs and opioid substitution treatment appear to have averted an epidemic, stabilised or substantially reduced the prevalence of HIV among injecting drug users. However, despite decades of vigorous advocacy and scientific evidence, the global coverage of needle and syringe programs and opioid substitution treatment falls well short of the levels required to achieve international HIV control.

Fifteen years of HIV surveillance among people who inject drugs: the Australian Needle and Syringe Program Survey 1995-2009

OBJECTIVES

Following bipartisan political support in Australia for the timely introduction of needle and syringe programs (NSPs), HIV prevalence among people who inject drugs (PWID) remains low. This study aimed to determine the correlates of HIV infection among PWID; and to examine these correlates over time.

DESIGN

Annual cross-sectional seroprevalence studies among attendees of sentinel NSP sites.

METHOD

Multiple logistic regressions conducted on aggregated, de-duplicated data from 1995 to 2009 to determine variables independently associated with HIV infection.

RESULTS

Data were available for 22 478 individual NSP attendees, equating to a mean annual response rate of 44% (range 38-60%). Two-thirds of participants were men, with a median age of 30 years, and a median of 10 years since first injection. Eighty-five percent identified as heterosexual, 10% as bisexual and 5% as homosexual. Serology was available for 21 248 participants, of whom 230 (1.1%) tested HIV antibody positive. Variables independently associated with antibody seropositivity were homosexual or bisexual identity; male sex; older age; older age at first injection; and survey participation between 1995 and 1997 rather than later periods.

CONCLUSIONS

Unlike settings in which evidence-based public health approaches to illicit drug policy are yet to be implemented, the epidemiology of HIV among NSP attendees mirrors that of Australia's general population, with the majority of exposures attributed to male-to-male sexual contact. This pattern has remained unchanged over 15 years despite significant variation in drug markets and patterns of drug use. NSPs also play a crucial role in this country's comprehensive HIV surveillance mechanisms.

Participant characteristics and HIV risk behaviors among individuals entering integrated buprenorphine/naloxone and HIV care

OBJECTIVE

This study was part of a national, multisite demonstration project evaluating the impact of integrated buprenorphine/naloxone treatment and HIV care. The goals of this study were to describe the baseline demographic, clinical, and substance use characteristics of the participants and to explore HIV transmission risk behaviors in this group.

METHODS

Nine sites across the United States participated. Data obtained by interview and chart review included demographic information, medical history, substance use, and risk behaviors.We performed a descriptive analysis of patient characteristics at entry and used logistic regression to evaluate factors associated with 1) unprotected anal or vaginal sex; and 2) needle-sharing within the previous 90 days.

RESULTS

Three hundred eighty-six individuals were included in the study: 303 (78.5%) received buprenorphine/naloxone; 41 (10.6%) received methadone; and 42 (10.9%) received another form of treatment. The analysis of risk behaviors was limited to those in the buprenorphine group (n = 303). Among those reporting vaginal or anal sex in the previous 90 days, 24% had sex without a condom. Factors significantly associated with unprotected sex were: having a partner; female gender; and alcohol use in previous 30 days. A total of 8.9% of participants shared needles in the previous 90 days. Factors significantly associated with needle-sharing were: amphetamine use; marijuana use; homelessness; and anxiety.

CONCLUSIONS

Addressing transmission risk behaviors is an important secondary HIV prevention strategy. In addition to treatment for opioid dependence, addressing other substance use, social issues, particularly housing, and mental health may have important implications for reducing HIV transmission in HIV-infected opioid-dependent patients.

Changes in blood-borne infection risk among injection drug users

BACKGROUND

Population-level hepatitis C virus (HCV) infection incidence is a surrogate for community drug-related risk.

METHODS

We characterized trends in human immunodeficiency virus (HIV) and HCV infection incidence and HCV infection prevalence among injection drug users (IDUs) recruited over 4 periods: 1988-1989, 1994-1995, 1998, and 2005-2008. We calculated HIV and HCV infection incidence within the first year of follow-up among IDUs whose test results were negative for these viruses at baseline (n = 2061 and n = 373, respectively). We used Poisson regression to compare trends across groups.

RESULTS

HIV infection incidence declined significantly from 5.5 cases/100 person-years (py) in the 1988-1989 group to 2.0 cases/100 py in the 1994-1995 group to 0 cases/100 py in the 1998 and 2005-2008 groups. Concurrently, HCV infection incidence declined but remained robust (22.0 cases/100 py in the 1988-1989 cohort to 17.2 cases/100 py in the 1994-1995 cohort, 17.9 cases/100 py in the 1998 cohort, and 7.8 cases/100 py in the 2005-2008 cohort; P = .07). Likewise, HCV infection prevalence declined, but chiefly in younger IDUs. For persons aged <39 years, relative to the 1988-1989 cohort, all groups exhibited significant declines (adjusted prevalence ratio [PR] for the 2005-08 cohort, .73; 95% confidence interval [CI], .65-.81). However, for persons aged ≥ 39 years, only the 2005-2008 cohort exhibited declining prevalence compared with the 1988-1989 cohort (adjusted PR, .87; 95% CI, .77-.99).

CONCLUSIONS

Although efforts to reduce blood-borne infection incidence have had impact, this work will need to be intensified for the most transmissible viruses, such as HCV.

HIV vaccine trial willingness among injection and non-injection drug users in two urban centres, Barcelona and San Francisco

Being able to recruit high-risk volunteers who are also willing to consider future participation in vaccine trials are critical features of vaccine preparedness studies. We described data from two cohorts of injection- and non-injection drug users in Barcelona, Spain [Red Cross centre] and in San Francisco, USA, [UFO-VAX study] at high risk of HIV/HCV infection to assess behaviour risk exposure and willingness to participate in future preventive HIV vaccine trials. We successfully identified drug-using populations that would be eligible for future HIV vaccine efficacy trials, based on reported levels of risk during screening and high levels of willingness to participate. In both groups, Red Cross and UFO-VAX respectively, HCV infection was highly prevalent at baseline (41% and 34%), HIV baseline seroprevalence was 4.2% and 1.5%, and high levels of willingness were seen (83% and 78%).

Tillotson C, Choi D, Robinson J, Calsyn DA, Mandler RN, Jenkins LM, Thompson LL, Dempsey CL, Liepman MR, McCarty D. Reducing HIV-related risk behaviors among injection drug users in residential detoxification

This study of 632 drug injectors enrolled in eight residential detoxification centers within the National Drug Abuse Treatment Clinical Trials Network tested three interventions to reduce drug and sex risk behaviors. Participants were randomized to: (a) a two-session, HIV/HCV counseling and education (C&E) model added to treatment as usual (TAU), (b) a one-session, therapeutic alliance (TA) intervention conducted by outpatient counselors to facilitate treatment entry plus TAU, or (c) TAU. Significant reductions in drug and sex risk behaviors occurred for all three conditions over a 6-month follow-up period. C&E participants reported significantly greater rates of attending an HIV testing appointment, but this was not associated with better risk reduction outcomes. Reporting treatment participation within 2 months after detoxification and self-efficacy to practice safer injection behavior predicted reductions in injection risk behaviors. Findings indicate that participation in detoxification was followed by significant decreases in drug injection and risk behaviors for up to 6-months; interventions added to standard treatment offered no improvement in risk behavior outcomes.

HIV and hepatitis B and C incidence rates in US correctional populations and high risk groups: a systematic review and meta-analysis

BACKGROUND

High Human Immunodeficiency Virus (HIV) prevalence and high risk behaviors have been well documented within United States (US) correctional systems. However, uncertainty remains regarding the extent to which placing people in prison or jail increases their risk of HIV infection, and regarding which inmate populations experience an increased incidence of HIV. Describing these dynamics more clearly is essential to understanding how inmates and former detainees may be a source for further spread of HIV to the general US population.

METHODS

The authors conducted a systematic review and meta-analysis of studies describing HIV incidence in US correctional facility residents and, for comparison, in high risk groups for HIV infection, such as non-incarcerated intravenous drug users (IVDU) and men who have sex with men (MSM) in the US. HIV incidence rates were further compared with Hepatitis B and Hepatitis C Virus rates in these same populations.

RESULTS

Thirty-six predominantly prospective cohort studies were included. Across all infection outcomes, continuously incarcerated inmates and treatment recruited IVDU showed the lowest incidence, while MSM and street recruited IVDU showed the highest. HIV incidence was highest among inmates released and re-incarcerated. Possible sources of heterogeneity identified among HIV studies were risk population and race.

CONCLUSIONS

Although important literature gaps were found, current evidence suggests that policies and interventions for HIV prevention in correctional populations should prioritize curtailing risk of infection during the post-release period. Future research should evaluate HIV incidence rates in inmate populations, accounting for proportion of high risk sub-groups.

Drug treatment as HIV prevention: a research update

Drug use continues to be a major factor fueling the global epidemic of HIV infection. This article reviews the current literature on the ability of drug treatment programs to reduce HIV transmission among injection and noninjection drug users. Most data come from research on the treatment of opiate dependence and provide strong evidence on the effectiveness of medication-assisted treatment for reducing the frequency of drug use, risk behaviors, and HIV infections. This has been a consistent finding since the epidemic began among diverse populations and cultural settings. Use of medications other than methadone (such as buprenorphine/naloxone and naltrexone) has increased in recent years with promising data on their effectiveness as HIV prevention and as new treatment options for communities heavily affected by opiate use and HIV infection. However, few treatment interventions for stimulant abuse and dependence have shown efficacy in reducing HIV risk. The cumulative literature provides strong support of drug treatment programs for improving access and adherence to antiretroviral treatment. Drug users in substance abuse treatment are significantly more likely to achieve sustained viral suppression, making viral transmission less likely. Although there are challenges to implementing drug treatment programs for maximum impact, the scientific literature leaves no doubt about the effectiveness of drug treatment as an HIV prevention strategy.

Methadone maintenance patients' knowledge, attitudes, beliefs, and experiences concerning treatment for hepatitis C virus infection

Hepatitis C virus (HCV) knowledge, attitudes, beliefs, and experiences (KABE) of 64 HCV antibody positive methadone maintenance treatment (MMT) patients were assessed in conjunction with acceptability of an on-site semi-structured HCV education session, HCV RNA diagnostic testing, HCV treatment motivational assessment, and initiation of HCV treatment. The KABE interviews were conducted in 2006 and 2007 in an urban New York State MMT clinic in affiliation with a NIDA-funded HCV research project. The majority had basic knowledge of HCV disease, but poor understanding of HCV testing and treatment. While the majority of participants expressed fear of HCV treatment side effects, 88% accepted HCV RNA testing and 78% expressed willingness to start HCV treatment with the majority of chronically infected choosing to start HCV treatment medications. Study limitations and implications are discussed.

An integrated drug counseling and employment intervention for methadone clients

After drug use stabilization, employment has long been considered an important goal for clients enrolled in Methadone Maintenance Treatment Programs (MMTPs). The integrated counseling and employment intervention described here is a manualized treatment based on interpersonal cognitive problem solving (ICPS) theory. The six-month intervention utilized a problem-solving framework to help methadone clients obtain a job and manage employment within the context of drug treatment. In this pilot study, 23 subjects were randomly assigned to either integrated ICPS drug and employment counseling (n = 12) or to an ICPS drug counseling control condition (n = 11). While there were no differences between the integrated and control conditions, both groups showed a significant improvement in employment outcomes and reduction in HIV risk behaviors at the six-month follow-up. Although there may be concerns regarding the generalizability of the findings, overall, the problem solving framework may be an improvement over standard methadone counseling. The intervention may be beneficial when implemented with a larger group of motivated ex-offenders who are mandated to drug treatment as a condition of their parole.

Open-label dose-finding trial of buprenorphine implants (Probuphine) for treatment of heroin dependence

Buprenorphine, a mu-opioid receptor partial agonist, has been shown to be safe and effective for treatment of opioid dependence. A novel implantable formulation of buprenorphine (Probuphine), using a polymer matrix sustained-release technology, has been developed to offer treatment for opioid dependence while minimizing risks of patient noncompliance and illicit diversion. The goal of the current study was to conduct an initial, open-label, evaluation of the safety, pharmacokinetics, and efficacy of two doses of Probuphine in subjects with opioid dependence maintained on sublingual buprenorphine. Two doses of Probuphine were evaluated in 12 heroin-dependent volunteers switched from daily sublingual buprenorphine dosing to either two or four Probuphine implants based upon their buprenorphine daily maintenance dose of 8 mg or 16 mg respectively, and were monitored for 6 months. Probuphine implants provided continuous steady state delivery of buprenorphine until their removal at 6 months. Withdrawal symptoms and craving remained low throughout the 6 months. For the 12 subjects, an average of 59% of urines were opioid-negative across the 6 month treatment period. Injection site reactions were present in half of patients, but none were serious. No safety concerns were evident. These results suggest that Probuphine implants offer significant promise for enhancing delivery of effective opioid substitution treatment while minimizing risk for abuse of medication.

Optimal investment in HIV prevention programs: more is not always better

This paper develops a mathematical/economic framework to address the following question: Given a particular population, a specific HIV prevention program, and a fixed amount of funds that could be invested in the program, how much money should be invested? We consider the impact of investment in a prevention program on the HIV sufficient contact rate (defined via production functions that describe the change in the sufficient contact rate as a function of expenditure on a prevention program), and the impact of changes in the sufficient contact rate on the spread of HIV (via an epidemic model). In general, the cost per HIV infection averted is not constant as the level of investment changes, so the fact that some investment in a program is cost effective does not mean that more investment in the program is cost effective. Our framework provides a formal means for determining how the cost per infection averted changes with the level of expenditure. We can use this information as follows: When the program has decreasing marginal cost per infection averted (which occurs, for example, with a growing epidemic and a prevention program with increasing returns to scale), it is optimal either to spend nothing on the program or to spend the entire budget. When the program has increasing marginal cost per infection averted (which occurs, for example, with a shrinking epidemic and a prevention program with decreasing returns to scale), it may be optimal to spend some but not all of the budget. The amount that should be spent depends on both the rate of disease spread and the production function for the prevention program. We illustrate our ideas with two examples: that of a needle exchange program, and that of a methadone maintenance program.

Why don't out-of-treatment individuals enter methadone treatment programmes?

BACKGROUND

Despite the proven effectiveness of methadone treatment, the majority of heroin-dependent individuals are out-of-treatment.

METHODS

Twenty-six opioid-dependent adults who met the criteria for methadone maintenance who were neither seeking methadone treatment at the time of study enrollment, nor had participated in such treatment during the past 12 months, were recruited from the streets of Baltimore, Maryland through targeted sampling. Ethnographic interviews were conducted to ascertain participants' attitudes toward methadone treatment and their reasons for not seeking treatment.

RESULTS

Barriers to treatment entry included: waiting lists, lack of money or health insurance, and requirements to possess a photo identification card. For some participants, beliefs about methadone such as real or rumored side effects, fear of withdrawal from methadone during an incarceration, or disinterest in adhering to the structure of treatment programmes kept them from applying. In addition, other participants were not willing to commit to indefinite "maintenance" but would have accepted shorter time-limited methadone treatment.

CONCLUSION

Barriers to treatment entry could be overcome by an infusion of public financial support to expand treatment access, which would reduce or eliminate waiting lists, waive treatment-related fees, and/or provide health insurance coverage for treatment. Treatment programmes could overcome some of the barriers by waiving their photo I.D. requirements, permitting time-limited treatment with the option to extend such treatment upon request, and working with corrections agencies to ensure continued methadone treatment upon incarceration.

High-risk sexual and drug using behaviors among male injection drug users who have sex with men in 2 Mexico-US border cities

OBJECTIVES

The population of Latino men who have sex with men (MSM) and who are also injection drug users (IDUs) is understudied. We explored risk behaviors of MSM/IDUs compared with other male IDUs in 2 Mexican border cities.

STUDY DESIGN

In 2005, IDUs who had injected within the previous 30 days were recruited using respondent-driven sampling (RDS) in Tijuana and Ciudad Juárez. They underwent antibody testing for HIV, HCV, and syphilis and interviewer-administered surveys. Men were categorized as MSM if they reported > or =1 lifetime male partners. Logistic regression was used to compare MSM/IDUs with non-MSM/IDUs.

RESULTS

A third (31%) of 377 male IDUs were categorized as MSM (47% in Tijuana and 13% in Ciudad Juárez, P <0.01). Combined RDS-adjusted prevalence of HIV and Hepatitis C was 3% (95% CI: 1, 5) and 96%, (95% CI: 94, 99) respectively, while 17% (95% CI: 2, 36) of MSM and 8% (95% CI: 3, 12) of non-MSM tested positive for syphilis antibody. In multivariate logistic regression adjusted for site, MSM/IDUs were more likely than non-MSM/IDUs to have ever used inhalants (OR: 3.4; 95% CI: 1.8, 6.2) or oral tranquilizers (OR: 2.4; 95% CI: 1.3, 4.6), received treatment for a drug problem (OR:1.9; 95% CI: 1.1, 3.2) shared needles in the last six months (OR: 2.1; 95% CI: 1.0, 4.2) and also had higher numbers of lifetime female partners (log-transformed continuous variable, OR: 1.6; 95% CI: 1.2, 2.1).

CONCLUSIONS

In these Mexican cities, the proportion of MSM among male IDUs was high. Compared with other male IDUs, MSM/IDUs were more likely to engage in behaviors placing them at risk of acquiring HIV/STIs. Culturally appropriate interventions targeting Latino MSM/IDUs are warranted.

Hepatitis C and human immunodeficiency virus risk behaviors in polydrug users on methadone maintenance

We examined the impact of methadone maintenance treatment (MMT) on risk behaviors for transmission of blood-borne diseases in polydrug users who had tested positive or negative for hepatitis C virus (HCV). At intake, HCV-positive participants (n=362) engaged in more human immunodeficiency virus (HIV) risk behaviors (as measured by the HIV Risk-Taking Behavior Scale) than HCV-negative participants (n=297; p< .001). This difference was specific to injection-related behaviors and decreased significantly within the first few weeks of MMT (p< .0001). Where needles continued to be used, HCV-positive participants became more likely over time to engage in safer injecting practices. Furthermore, HCV-positive participants became more likely to use condoms than HCV-negative participants. These findings demonstrate that both drug- and sex-related risk behaviors decrease during MMT and emphasize the benefits of methadone programs for public health and HIV/HCV prevention.

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.

Evaluation of the overall program effectiveness of HIV-related intervention programs in a community in Sichuan, China

OBJECTIVES

The study evaluates the overall effectiveness of intervention programs among female sex workers in a Chinese community.

STUDY DESIGN

Behavioral surveillance data in 2003, 2004, and 2005 obtained from 2 communities (intervened and control) were compared.

RESULTS

The baseline data (2003) of the 2 counties were not significantly different. In 2004 and 2005, the intervened county had significantly higher prevalence of condom use with their clients and regular sex partners (last-time and consistent use in the last month; OR = 2.2-33.2 in 2004 and 3.8-8.3 in 2005), higher HIV-related knowledge level (OR = 7.9 in 2004 and 17.3 in 2005), and lower STD prevalence (OR = 0.22 in 2004 and 0.11 in 2005). Coverage rates of HIV antibody testing and HIV-related services increased in the intervened county but decreased in the control county.

CONCLUSIONS

Intervention programs may result in substantial behavioral changes in a community within a few years.

Diagnosis and management of acute HIV infection

HIV infection starts as an acute, systemic infection, followed by a chronic period of clinical latency, usually lasting 3 to 10 years, which precedes the eventual collapse of the immune system. It is increasingly recognized that events occurring during acute HIV infection may determine the natural course of the disease. The very dynamic events of acute HIV infection provide multiple opportunities for biologic interventions, such as anti-retroviral or immune-based therapies. Similarly, the implementation of public health measures during acute HIV infection could help control epidemics or outbreaks. Many of the dramatic possibilities for intervention in acute HIV infection remain unproved, not the least because of traditional difficulty of diagnosing patients during this early period. This article reviews the natural history, pathogenesis and clinical presentation of acute HIV infection, and suggests a diagnostic and therapeutic approach to guide clinicians dealing with patients with suspected or confirmed acute HIV infection.

Treatment entry and predictors among opiate-using injection drug users

This study examines entry into drug treatment among 491 street-recruited injection drug users in Denver, Colorado. The primary outcome was treatment entry within 6 months. Univariate tests were run using chi-square t-test analyses. Significant variables were included in a multiple logistic regression. Results showed that having more outreach contacts, not being homeless, having fewer problems with alcohol but more problems with drugs, and the contemplation or determination stage of change were associated with entering treatment. The identification of predictors of treatment entry may be useful for treatment centers in engaging certain populations of drug users. Behavioral interventions are an important tool in recruiting drug injectors into treatment.

HIV incidence among injection drug users in Baltimore, Maryland (1988-2004)

BACKGROUND

We examined recent trends (1999-2004) in HIV incidence among a cohort of injection drug users (IDUs) followed since 1988 in Baltimore, Maryland.

METHODS

One thousand eighty-three HIV-seronegative individuals with a history of injection drug use were recruited between 1988 and 1998 and returned for >or=1 semiannual follow-up visit, where they underwent HIV antibody testing and interviews eliciting risk behaviors. Person-time methods were used to calculate HIV incidence rates per 100 person-years (PYs).

RESULTS

Over 14,770 PYs, 304 individuals seroconverted to HIV (2.06 per 100 PYs). Annual incidence declined from 4.57 in 1988 to 0.53 per 100 PYs in 2004. Similarly, among individuals actively injecting drugs, incidence steadily declined from 5.43 in 1988 to 0 in 2004, with the exception of 2003, when an incidence of 2.59 per 100 PYs was observed. Reported sexual risk behaviors and drug injection declined from 1988 through 2004, but among those actively injecting, reported needle sharing declined from 1988 through 1998 and then increased from 30% in 1998 to nearly 40% in 2003 through 2004.

CONCLUSIONS

Long-term declines in HIV incidence among IDUs are consistent with other reports; however, in 2003, we observed an unexpected increase in seroconversion that seems to be related to needle sharing. Although additional follow-up is needed to identify trends, these data indicate the need to reinforce HIV prevention efforts and to continue surveillance of drug users' behaviors.

The medical management of opioid dependence in HIV primary care settings

Injecting drug use is a common mode of transmission among persons with HIV/AIDS. Many HIV-infected patients meet diagnostic criteria for opioid dependence, a chronic and relapsing brain disorder. Most HIV providers, however, receive little training in substance use disorders. Opioid agonist therapy (OAT) has a stabilizing effect on opioid-dependent patients and is associated with greater acceptance of antiretroviral (ARV) therapy, higher ARV adherence, and greater engagement in HIV-related health care. Although methadone maintenance has been the OAT gold standard, methadone is available for the treatment of opioid dependence only in strictly regulated narcotic treatment programs. Buprenorphine, a partial opioid agonist approved for the office-based treatment of opioid dependence in 2002, may result in better health and substance use treatment outcomes for patients with HIV disease.

Assessing the effects of human mixing patterns on human immunodeficiency virus-1 interhost phylogenetics through social network simulation

Geneticists seeking to understand HIV-1 evolution among human hosts generally assume that hosts represent a panmictic population. Social science research demonstrates that the network patterns over which HIV-1 spreads are highly nonrandom, but the effect of these patterns on the genetic diversity of HIV-1 and other sexually transmitted pathogens has yet to be thoroughly examined. In addition, interhost phylogenetic models rarely account explicitly for genetic diversity arising from intrahost dynamics. This study outlines a graph-theoretic framework (exponential random graph modeling, ERGM) for the estimation, inference, and simulation of dynamic partnership networks. This approach is used to simulate HIV-1 transmission and evolution under eight mixing patterns resembling those observed in empirical human populations, while simultaneously incorporating intrahost viral diversity. Models of parametric growth fit panmictic populations well, yielding estimates of total viral effective population on the order of the product of infected host size and intrahost effective viral population size. Populations exhibiting patterns of nonrandom mixing differ more widely in estimates of effective population size they yield, however, and reconstructions of population dynamics can exhibit severe errors if panmixis is assumed. I discuss implications for HIV-1 phylogenetics and the potential for ERGM to provide a general framework for addressing these issues.

Access to highly active antiretroviral therapy for injection drug users: adherence, resistance, and death

Injection drug users (IDUs) continue to comprise a major risk group for HIV infection throughout the world and represent the focal population for HIV epidemics in Asia and Eastern Europe/Russia. HIV prevention programs have ranged from HIV testing and counseling, education, behavioral and network interventions, drug abuse treatment, bleach disinfection of needles, needle exchange and expanded syringe access, as well as reducing transition to injection and primary substance abuse prevention. With the advent of highly active antiretroviral therapy (HAART) in 1996, dramatic clinical improvements have been seen. In addition, the treatment's impact on reducing HIV viral load (and therefore transmission by all routes) provides a stronger rationale for an expansion of the focus on prevention to emphasize early identification and treatment of HIV infected individuals. However, treatment of IDUs has many challenges including adherence, resistance and relapse to high risk behaviors, all of which impact issues of access and ultimately effectiveness of potent antiretroviral treatment. A major current challenge in addressing the HIV epidemic revolves around an appropriate approach to HIV treatment for IDUs.

Social contextual factors associated with entry into opiate agonist treatment among injection drug users

We tested hypotheses that social living arrangement and drug use in one's network are independently associated with entry into opiate agonist treatment modalities. Injection drug users (IDUs) attending the Baltimore Needle Exchange Program who received a referral for drug abuse treatment were studied. Baseline interviews, HIV testing, and the Addiction Severity Index (ASI) were administered. Agency records were used to confirm entry into a treatment program offering opiate agonist maintenance therapy within 30 days of the baseline interview. Logistic regression was used to identify predictors of treatment entry. To date, of 245 IDUs, 39% entered such a program. Multivariate logistic regression models controlling for age and intervention status revealed that compared to individuals who lived alone, in a controlled, or nonstable environment (e.g., streets, abandoned house, transitional housing program, or boarding house), individuals who lived with a sexual partner were 3 times more likely to enter treatment (adjusted Odds Ratio [aOR]=3.04; p=0.013) and those who lived with family or friends were almost 3 times more likely to enter treatment (aOR=2.72; p=0.016). In the bivariate analyses, a marginal association was observed between being responsible for children or others and entry into treatment (p=0.066); however, this association was not significant in the multivariate model. Findings from this study suggest that supportive living environments may facilitate entry into treatment and may be helpful in devising appropriate and targeted interventions to encourage drug treatment entry.

Brief report: Methadone treatment of injecting opioid users for prevention of HIV infection

OBJECTIVE

To assess the effects of oral substitution treatment for opioid-dependent injecting drug users on HIV risk behaviors and infections.

DATA SOURCES

Multiple electronic databases were searched. Reference lists of retrieved articles were checked.

METHODS

Because of varying methodologies of available studies, this systematic review was limited to a descriptive summary, looking at consistency of outcomes across studies.

RESULTS

Twenty-eight studies involving methadone treatment were included in the review. Methadone maintenance treatment is associated with statistically significant reductions in injecting use and sharing of injecting equipment. It is also associated with reductions in numbers 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 behaviors do translate into fewer cases of HIV infection.

CONCLUSIONS

Methadone maintenance treatment for injecting drug users significantly reduces the risk of transmission of HIV and should be provided as a component of a strategic approach to the prevention and control of HIV infection. There is insufficient evidence to determine whether other forms of oral substitution treatment also reduce the risk of HIV transmission.

HIV seroconversion among the homeless and marginally housed in San Francisco: a ten-year study

HIV seroprevalence was previously found to be 9-11% among the urban homeless in San Francisco, with most infections among injection drug users, men who have sex with men, and those who exchange sex for money or drugs. In this study, HIV incidence and risk factors for seroconversion were estimated among persons who repeatedly participated in cross-sectional serosurveys over a period of 10 years. There were 6 seroconversions among 799 HIV-negative persons, for an incidence rate of 0.30% per person-year (95% CI: 0.12-0.61% per person-year). The seroconversion rate among men who had had recent sex with men was 1.22% per person-year (95% CI: 0.29-3.18) and was 0.52% per person-year (95% CI: 0.19-1.13% per person-year) among those who ever injected drugs. The seroconversion rate among those who were aged <30 years at baseline was 1.67% per person-year (95% CI: 0.40-4.36% per person-year), which was significantly higher than for those age > or =30 years. Policy implications are that HIV resources aimed at the more stable, older homeless population should probably focus on treatment, while prevention efforts, conversely, should probably be targeted to younger homeless persons.

Buprenorphine: Its Role in Preventing HIV Transmission and Improving the Care of HIV-Infected Patients with Opioid Dependence

In the United States, approximately 25% of the 40,000 new human immunodeficiency virus (HIV) infections each year are secondary to injection drug use. Worldwide, there are an estimated 12.6 million injection drug users, and 10% of HIV infections (420,000 infections in 2003) are associated with this practice. Buprenorphine is a new medication used to treat opioid dependence that shows promise for reducing the rate of HIV transmission and improving the care of opioid-dependent patients with HIV infection. Although buprenorphine faces fewer clinical and regulatory barriers than does methadone, the optimal strategy for integration of office-based treatment of opioid dependence and HIV disease is an area of ongoing research. This review addresses the introduction of buprenorphine, in terms of public health, policy, and clinical implications for HIV-infected patients and for HIV care providers.

Four-year follow-up of imprisoned male heroin users and methadone treatment: mortality, re-incarceration and hepatitis C infection

AIMS

To examine the long-term impact of methadone maintenance treatment (MMT) on mortality, re-incarceration and hepatitis C seroconversion in imprisoned male heroin users.

DESIGN, SETTING AND PARTICIPANTS

The study cohort comprised 382 imprisoned male heroin users who had participated in a randomized controlled trial of prison-based MMT in 1997/98. Subjects were followed-up between 1998 and 2002 either in the general community or in prison.

MEASUREMENTS

All-cause mortality, re-incarceration, hepatitis C and HIV serostatus and MMT retention.

FINDINGS

There were no deaths recorded while subjects were enrolled in MMT. Seventeen subjects died while out of MMT, representing an untreated mortality rate of 2.0 per 100 person-years (95% CI, 1.2-3.2). Re-incarceration risk was lowest during MMT episodes of 8 months or longer (adjusted hazard ratio 0.3 (95% CI, 0.2-0.5; P < 0.001), although MMT periods 2 months or less were associated with greatest risk of re-incarceration (P < 0.001). Increased risk of hepatitis C seroconversion was significantly associated with prison sentences of less than 2 months [adjusted hazard ratio 20 (95% CI, 5-76; < P = 0.001)] and MMT episodes less than 5 months [adjusted hazard ratio 4.2 (95% CI, 1.4-12.6; P = 0.01)]. Subjects were at greatest risk of MMT dropout during short prison sentences of 1 month or less (adjusted hazard ratio 10.4 (95% CI, 7.0-15.7; P < 0.001). HIV incidence was 0.3 per 100 person-years (95% CI, 0.03-0.99).

CONCLUSIONS

Retention in MMT was associated with reduced mortality, re-incarceration rates and hepatitis C infection. Prison-based MMT programmes are integral to the continuity of treatment needed to ensure optimal outcomes for individual and public health.

Drug use among female sex workers in Hanoi, Vietnam

AIMS

To describe the drug use practices among female sex workers (FSWs) in Hanoi and to identify factors associated with their drug injecting.

DESIGN, SETTING AND PARTICIPANTS

A two-stage cluster survey of 400 FSWs was conducted from June to September, 2002. Participating FSWs were both establishment- (160) and street-based (240), who were practising in seven urban and one suburban districts of Hanoi.

MEASUREMENTS

Subjects were interviewed face to face using a structured questionnaire.

FINDINGS

Among the middle-class FSWs, 27% used drugs, of whom 79% injected. Among low-class FSWs, 46% used drugs and 85% injected. Among drug-using FSWs, 86% had started using drugs within the past 6 years. Among drug-injecting FSWs, 81% had started injecting within the past 4 years. Cleaning of injecting equipment was not common among those who shared. Having drug-injecting 'love mates', drug-using clients, longer residence in Hanoi, more clients and not currently cohabiting were found to be independently associated with drug injecting among FSWs.

CONCLUSIONS

The high prevalence of injecting drug use among FSWs makes them susceptible to HIV infection, and is a threat to their clients. There is a strong relationship between drug-using FSWs and male drug-using clients and non-client partners. Intervention to prevent drug use initiation among non-drug-using FSWs and harm reduction among drug-using FSWs are urgently needed.

Recruiting drug-using men who have sex with men into behavioral interventions: a two-stage approach

Drug-using men who have sex with men (MSM) are at high risk of acquiring or transmitting HIV infection. Efforts to change behaviors in this population have been hampered by difficulties in recruiting drug-using MSM into behavioral interventions. This study sought to develop an effective strategy for recruiting drug-using MSM into behavioral interventions that consist of motivational interviewing alone or motivational interviewing plus contingency management. MSM were recruited through advertising and community outreach into groups to discuss party drugs, party burnout, and sexual behavior, with the intervention subsequently described and enrollment offered in the group setting. Many more eligible MSM responded to advertisements for the discussion groups than advertisements for the interventions, and 58% of those who participated in the discussion groups volunteered for counseling. Men who entered counseling reported high levels of drug use and sexual activity and were racially and ethnically diverse; only 35% were willing to accept drug treatment. Results demonstrate that a two-stage strategy in which drug-using MSM are first recruited into discussion groups before they are offered a behavioral intervention can be an effective way to induce voluntary acceptance of an intervention employing a behavioral risk-reduction approach.

Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users

AIMS

To examine the role of expanded access to opioid agonist treatment as a means to decrease international HIV transmission.

DESIGN

Review of the English language literature via Medline.

MEASUREMENTS

Estimates of prevalence rates for injection drug use, HIV infection and treatment effect sizes for changes in opioid use, opioid injection, needle-sharing, injection-related HIV risk behavior and cost.

FINDINGS

An estimated 12.6 million injection drug users internationally accounted for 10% of the 4.2 million new HIV infections in 2003. Ninety-three of the 136 countries (68%) that report injection drug use identify HIV infection related to this behavior. Observational studies of methadone treatment demonstrate decreases in opioid use, opioid injection, needle-sharing and lower rates of HIV prevalence and incidence. The effectiveness of buprenorphine in demonstrating similar findings is expected, although implementations and research are still emerging. The cost-effectiveness of opioid agonist treatment has been established. The barriers to international adoption of opioid agonist treatment, despite the research evidence and international guidelines, are discussed.

CONCLUSIONS

Untreated opioid dependence leads to HIV transmission, on an international level. Opioid agonist treatments are associated with reductions in the frequency of opioid use, fewer injections and injection-related HIV risk behaviors and lower rates of HIV prevalence and incidence. Despite international recommendations, treatment for opioid-dependent injection drug users with methadone and buprenorphine is limited. Research, implementation efforts and political strategies to expand access to opioid agonist treatment are needed in order to combat the spread of HIV, especially in the developing world.

Sexual behavior patterns of methamphetamine-using gay and bisexual men

We assessed the sexual behaviors of 49 gay and bisexual methamphetamine users in New York City and the relationship between their use of the substance and their sexual practices as part of a larger investigation of the behavioral aspects of methamphetamine use. Participants were assessed on their use of methamphetamine and their sexual behaviors in conjunction with use of the substance. Participants reported equivalent rates of unprotected anal insertive and receptive behaviors when comparing their sexual acts while high on methamphetamine, high on other drugs, and sober. In addition, equivalent rates of "extreme" sex acts were found for 10 of the 12 behaviors examined while high on methamphetamine and while sober. While wefound few differences in terms of rates of sexual behaviors, our analysis revealed more frequent risky sexual behaviors among HIV positive men when compared with HIV negative men. Our results suggest that methamphetamine attracts a hypersexual risk-taking group of men who engage in unprotected sexual behaviors regardless of their methamphetamine use. Treatment implications are discussed.