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

Why young people's substance use matters for global health

During puberty, when young people are completing their education, transitioning into employment, and forming longer-term intimate relationships, a shift in emotional regulation and an increase in risky behaviour, including substance use, is seen. This Series paper considers the potential effects of alcohol, tobacco, and illicit drug use during this period on: social, psychological, and health outcomes in adolescence and young adulthood; role transitions, and later health and social outcomes of regular substance use initiated in adolescence; and the offspring of young people who use substances. We sourced consistent support for causal relations between substance use and outcomes and evidence of biological plausibility from different but complementary research designs. Many adverse health and social outcomes have been associated with different types of substance use. The major challenge lies in deciding which are causal. Furthermore, qualitatively different harms are associated with different substances, differences in life stage when these harms occur, and the quality of evidence for different substances and health outcomes varies substantially. The preponderance of evidence comes from a few high-income countries, thus whether the same social and health outcomes would occur in other countries and cultures is unclear. Nonetheless, the number of harms that are causally related to substance use in young people warrant high-quality research design interventions to prevent or ameliorate these harms.

A cross-national analysis of the effects of methadone maintenance and needle and syringe program implementation on incidence rates of HIV in Europe from 1995 to 2011

Although many studies have found an association between harm reduction interventions and reductions in incidence rates of Human Immunodeficiency Virus (HIV) infection, scant research explores the effects of harm reduction cross-nationally. This study used a year- and country-level fixed effects model to estimate the potential effects of needle-and-syringe programs (NSPs) and methadone maintenance therapy (MMT) on incidence rates of HIV in the general population and among people who inject drugs (PWID), in a sample of 28 European nations. After adjusting for Gross Domestic Product (GDP) and total expenditures on healthcare, we identified significant associations between years of MMT and NSP implementation and lower incidence rates of HIV among PWID and the general population. In addition to years of implementation of NSP and MMT, the greater proportion of GDP spent on healthcare was associated with a decrease in logged incidence rates of HIV. The findings of this study suggest that MMT and NSP may reduce incidence rates of HIV among PWID cross-nationally. The current study opens a new avenue of exploration, which allows for a focus on countrywide policies and economic drivers of the epidemic. Moreover, it highlights the immense importance of the adoption of harm reduction programs as empirically-based health policy as well as the direct benefits that are accrued from public spending on healthcare on incidence rates of HIV within the general population and among subpopulations of PWID.

In Their Own Voices: Breaking the Vicious Cycle of Addiction, Treatment and Criminal Justice Among People who Inject Drugs in Ukraine

AIMS

To understand how perceived law enforcement policies and practices contribute to the low rates of utilization of opioid agonist therapies (OAT) among people who inject drugs (PWIDs) in Ukraine.

METHODS

Qualitative data from 25 focus groups (FGs) with 199 opioid-dependent PWIDs in Ukraine examined domains related to lived or learned experiences with OAT, police, arrest, incarceration, and criminal activity were analyzed using grounded theory principles.

FINDINGS

Most participants were male (66%), in their late 30s, and previously incarcerated (85%) mainly for drug-related activities. When imprisoned, PWIDs perceived themselves as being "addiction-free". After prison-release, the confluence of police surveillance, societal stress contributed to participants' drug use relapse, perpetuating a cycle of searching for money and drugs, followed by re-arrest and re-incarceration. Fear of police and arrest both facilitated OAT entry and simultaneously contributed to avoiding OAT since system-level requirements identified OAT clients as targets for police harassment. OAT represents an evidence-based option to 'break the cycle', however, law enforcement practices still thwart OAT capacity to improve individual and public health.

CONCLUSION

In the absence of structural changes in law enforcement policies and practices in Ukraine, PWIDs will continue to avoid OAT and perpetuate the addiction cycle with high imprisonment rates.

Quality of Care and Service Expansion for HIV Care and Treatment

The last two decades have seen exceptional development of antiretroviral treatment programs throughout the world. Over 14 million persons are accessing antiretroviral treatment (ART) treatment as of early 2015, and life expectancy has risen markedly in the most-affected populations. However, large patient numbers threaten to overwhelm already over-burdened health care systems and retention in care remains suboptimal. Developing innovative strategies to alleviate these burdens and retain patients in care remains a challenge. Furthermore, despite this expansion, large populations of HIV-infected persons remain undiagnosed and are unwilling or unable to access care and treatment programs. Marginalized and high-risk populations are particularly in danger of remaining outside of care and are also disproportionately affected by HIV. To reverse the trend and "fast track" our way out of the epidemic, ambitious treatment targets are required, and a concerted effort has to be made to engage these populations into care, initiate ART, and attain viral suppression.

Towards "evidence-making intervention" approaches in the social science of implementation science: The making of methadone in East Africa

In this commentary, we take the recent introduction of methadone treatment in response to emerging problems of HIV linked to heroin addiction in Kenya as a case for reflecting on the social science of implementation science. We offer a framework of 'evidence-making intervention' which we hold as distinct from mainstream 'evidence-based intervention' approaches. Whilst accepting that interventions are shaped in their contexts, evidence-based intervention approaches tend to imagine a stable intervention object with universal effect potential. By contrast, an evidence-making intervention approach investigates how an intervention, and the knowledge which constitutes it, is made locally, through its processes of implementation. Drawing on qualitative research generated in Kenya prior to (2012-2013) and during (2014-2015) the implementation of methadone treatment, we explore the making of 'methadone promise' as a case of evidence-making intervention. We show how enactments of methadone promise make multiple methadones, through which a binary is negotiated between the narratives of methadone as hope for addiction recovery and methadone as hope for HIV prevention. Addiction recovery narratives predominate, despite methadone's incorporation into policy via its globally supported HIV prevention evidence-base. Key practices in the making of methadone promise in Kenya include its medicalization, and renaming, as 'medically assisted treatment' - or simply 'MAT' - which distance it from prior constitutions elsewhere as a drug of substitution, and the visualisation of its effects wherein unhealthy people can be seen and shown to have become well. We also show how actors seek to protect the story of methadone promise from counter narratives, including through mass media projects. We conclude that there is no single biomedical object of methadone intervening on a single biological body across contexts, and no single universe of evidence. By giving weight to local rather than outside expert knowledge, and by tracing how the meaning of intervention is made locally through its implementation, we can make visible the multiple enactments of an intervention and how these shape local ecologies of care, including in ways beyond those foreseen by an intervention's evidencing elsewhere.

Effectiveness of needle/syringe programmes and opiate substitution therapy in preventing HCV transmission among people who inject drugs

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the impact of needle/syringe programmes with and without opiate substitution therapy (OST) on the incidence of HCV infection among people who inject drugs (PWID).To assess the effect of OST alone on the incidence of HCV infection among PWID.

RESEARCH QUESTIONS

How effective are needle/syringe programmes (NSP) with and without the use of OST for reducing HCV incidence among PWID?How effective is OST alone for reducing HCV incidence among PWID?How does the effect of NSP and OST vary according to duration of treatment (i.e. for NSPs weekly attendance versus monthly)?How does the effect of NSP vary according to the type of service (fixed site versus mobile; high coverage versus low coverage)?How does the effect of OST vary according to the dosage of OST, type of substitution used and adherence to treatment?

Incarcerated intravenous heroin users: predictors of post-release utilization of methadone maintenance treatment

Incarcerated intravenous heroin users have more problematic patterns of heroin use, but are less likely to access methadone maintenance treatment by their own initiative than heroin users in the community. The present study examined predictors for receiving methadone maintenance treatment post-release among incarcerated intravenous heroin users within a 24-month period. This cohort study recruited 315 incarcerated intravenous heroin users detained in 4 prisons in southern Taiwan and followed up within the 24-month period post-release. Cox proportional hazards regression analysis was applied to determine the predictive effects of sociodemographic and drug-use characteristics, attitude toward methadone maintenance treatment, human immunodeficiency virus serostatus, perceived family support, and depression for access to methadone maintenance treatment after release. There were 295 (93.7%) incarcerated intravenous heroin users released that entered the follow-up phase of the study. During the 24-month follow-up period, 50.8% of them received methadone maintenance treatment. After controlling for the effects of the detainment period before and after recruitment by Cox proportional hazards regression analysis, incarcerated intravenous heroin users who had positive human immunodeficiency virus serostatus (HR = 2.85, 95% CI = 1.80-4.52, p < .001) and had ever received methadone maintenance treatment before committal (HR = 1.94, 95% CI = 1.23-3.05, p < .01) were more likely to enter methadone maintenance treatment within the 24-month follow-up period. Positive human immunodeficiency virus serostatus with fully subsidized treatment and previous methadone maintenance treatment experiences predicted access of methadone maintenance treatment post-release. Strategies for getting familiar with methadone maintenance treatment during detainment, including providing methadone maintenance treatment prior to release and lowering the economic burden of receiving treatment, may facilitate entry of methadone maintenance treatment for incarcerated intravenous heroin users.

Imprisonment of opioid-dependent people in New South Wales, Australia, 2000–2012: a retrospective linkage study

There are few data about the incarceration of opioid-dependent people involving large representative cohorts. We aimed to determine the prevalence and duration of incarceration in a large cohort of opioid-dependent people in Australia using data linkage methods, and estimate the costs associated with their incarceration.Method: Retrospective linkage study of all entrants to opioid substitution therapy (OST) for the treatment of opioid dependence in NSW, 1985–2010, with data on incarceration, 2000-2012. The number and duration of incarcerations were calculated. The average daily cost of incarceration was applied to days of incarceration in the cohort.Results: Among 47,196 opioid-dependent people, 37% (43% of men and 24% of women) had at least one episode of incarceration lasting one or more days. Men had a median of three(ranging between 1-47) incarcerations, and women, two (1-35). Indigenous men spent 23% of follow-up time incarcerated, compared with 8% for non-Indigenous men; similarly, Indigenous women spent a substantially greater proportion of time incarcerated than non-Indigenous women (8% vs. 2%). Costs of incarceration of this cohort between 2000 and 2012 totalled nearly AUD $3 billion.Conclusions: This is the first study to examine incarceration of opioid-dependent people across an entire population of such users. Our findings suggest that a substantial minority of opioid-dependent people experience incarceration, usually on multiple occasions and at significant cost. Treatment for opioid dependence, inside and outside prisons, may help reduce incarceration of this cohort.

Emergence of methadone as a street drug in St. Petersburg, Russia

BACKGROUND

The syndemic of opioid addiction, HIV, hepatitis, tuberculosis, imprisonment, and overdose in Russia has been worsened by the illegality of opioid substitution therapy. As part of on-going serial studies, we sought to explore the influence of opioid availability on aspects of the syndemic as it has affected the city of St. Petersburg.

METHODS

We employed a sequential approach in which quantitative data collection and statistical analysis were followed by a qualitative phase. Quantitative data were obtained in 2013-2014 from a respondent-driven sample (RDS) of people who inject drugs (PWID). Individuals recruited by RDS were tested for antibodies to HIV and interviewed about drug use and injection practices, sociodemographics, health status, and access to medical care. Subsequently, we collected in-depth qualitative data on methadone use, knowledge, and market availability from PWID recruited at nine different locations within St. Petersburg.

RESULTS

Analysis of interview data from the sample revealed the percentage of PWID injecting methadone in the 30 days prior to interview increased from 3.6% in 2010 to 53.3% in 2012-2013. Injection of only methadone, as compared to injecting only heroin or both drugs, was associated with less frequent injection and reduced HIV-related injected risk, especially a lower rate of injecting with a previously used syringe. In-depth questioning of methadone injectors corroborated the finding from serial quantitative surveys of PWID that methadone's black market availability is a recent phenomenon. Spatial analysis revealed widespread methadone availability but no concentration in any specific districts of the city.

CONCLUSION

Despite the prohibition of substitution therapy and demonization of methadone, the drug has emerged to rival heroin as the most commonly available opioid in St. Petersburg. Ironically, its use is associated with reduced injection-related HIV risk even when its use is illegal.

Opiate addiction therapies and HIV-1 Tat: interactive effects on glial [Ca²⁺]i, oxyradical and neuroinflammatory chemokine production and correlative neurotoxicity

Few preclinical studies have compared the relative therapeutic efficacy of medications used to treat opiate addiction in relation to neuroAIDS. Here we compare the ability of methadone and buprenorphine, and the prototypic opiate morphine, to potentiate the neurotoxic and proinflammatory ([Ca²⁺]i, ROS, H2O2, chemokines) effects of HIV-1 Tat in neuronal and/or mixed-glial co-cultures. Repeated observations of neurons during 48 h exposure to combinations of Tat, equimolar concentrations (500 nM) of morphine, methadone, or buprenorphine exacerbated neurotoxicity significantly above levels seen with Tat alone. Buprenorphine alone displayed marked neurotoxicity at 500 nM, prompting additional studies of its neurotoxic effects at 5 nM and 50 nM concentrations ± Tat. In combination with Tat, buprenorphine displayed paradoxical, concentration-dependent, neurotoxic and neuroprotective actions. Buprenorphine neurotoxicity coincided with marked elevations in [Ca²⁺]i, but not increases in glial ROS or chemokine release. Tat by itself elevated the production of CCL5/RANTES, CCL4/MIP-1β, and CCL2/MCP-1. Methadone and buprenorphine alone had no effect, but methadone interacted with Tat to further increase production of CCL5/RANTES. In combination with Tat, all drugs significantly increased glial [Ca²⁺]i, but ROS was only significantly increased by co-exposure with morphine. Taken together, the increases in glial [Ca²⁺]i, ROS, and neuroinflammatory chemokines were not especially accurate predictors of neurotoxicity. Despite similarities, opiates displayed differences in their neurotoxic and neuroinflammatory interactions with Tat. Buprenorphine, in particular, was partially neuroprotective at a low concentration, which may result from its unique pharmacological profile at multiple opioid receptors. Overall, the results reveal differences among addiction medications that may impact neuroAIDS.

Comparison of behavioral characteristics of dogs in the United States and Japan

This study examined the difference in dog owning between Japan and the United States, and the effect of these differences on dogs' behavioral characteristics. Behavioral evaluations of privately-owned dogs were obtained by using online questionnaire. We compared background and demographic information from the two countries and analyzed the effects of these differences on behavioral characteristics in dogs. The results indicated that there was a bias in the dog breeds kept in Japan compared to the United States and that Japanese dogs' body weight was lower than the US dogs. The main source of dog acquisition was pet stores in Japan and breeders and/or shelters in the United States. Multiple linear regression analysis found that Japanese dogs showed more aggression to household members and higher energy, restlessness and fear of non-social stimuli than US dogs, while US dogs showed more fear of unfamiliar persons, separation-related behavior and excitability. US dogs also showed higher levels of trainability and attachment to owners. The lower dog's body weight was, the higher the behavioral scores except for trainability were. When dogs that were obtained under 3 months of age were analyzed, the younger the dogs were when their owners obtained them, the higher the scores on some behavioral problem factors were. The higher rates of problem behaviors among Japanese dogs compared with US dogs suggest that the preference for small breed dogs and poor early development environment influenced the behavioral characteristics of dogs.

Cross-sectional assessments of participants' characteristics and loss to follow-up in the first Opioid Substitution Therapy Pilot Program in Kabul, Afghanistan

Background

Kabul has over 12,000 people who inject drugs (PWID), most of them heroin users, and opioid substitution therapy has recently been introduced as an effective method to reduce opioid use. We aimed to evaluate a pilot Opioid Substitution Therapy Pilot Program (OSTPP) in Kabul, Afghanistan, particularly to (1) describe characteristics of the participants enrolled in the program and (2) identify factors associated with client retention in the OSTPP.

Findings

Two cross-sectional surveys evaluated participants attending the OSTPP at baseline (n = 83) and 18 months after (n = 57). Questionnaires assessed socio-demographic, drug use behavior, and general and mental health factors. After 18 months, 57 participants remained in the OSTPP. Participants lost to follow-up were younger (p < 0.01) and married (p < 0.01) and had no family contact (p < 0.01). Participants at 18 months reported no criminal activity in the last month and only two (3.5 %) reported heroin use in the last month, constituting significant decreases from baseline.

Conclusions

While preliminary results are promising, further evaluation is needed to determine the feasibility of implementing OSTPP in this setting and effectiveness in reducing injection risk behaviors in Afghanistan.

Controlling HIV among people who inject drugs in Eastern Europe and Central Asia: insights from modeling

BACKGROUND

Although there is evidence of the effectiveness of needle and syringe programme (NSP), opioid substitution therapy (OST) and antiretroviral therapy (ART) in reducing HIV prevalence, most Central and Eastern European sub-regions still have low or no coverage of most or all of these interventions.

METHODS

We conducted a modelling analysis to consider the potential impact on HIV incidence and prevalence of OST, NSP and ART in three illustrative epidemic scenarios: Russia (St. Petersburg); Estonia (Tallinn) and Tajikistan (Dushanbe). For each intervention, we consider the coverage needed of each intervention separately or in combination to: (1) achieve a 30% or 50% relative reduction in HIV incidence or prevalence over 10 years; and (2) reduce HIV incidence to below 1% or HIV prevalence below 10% after 20 years. A sensitivity analysis for St. Petersburg considered the implications of greater on no risk heterogeneity, none or more sexual HIV transmission, like-with-like mixing, different injecting cessation rates and assuming a lower HIV acute phase cofactor.

RESULTS

For St. Petersburg, when OST, NSP and ART are combined, only 14% coverage of each intervention is required to achieve a 30% reduction in HIV incidence over 10 years. Similar findings are obtained for Tallinn and Dushanbe. In order to achieve the same reductions in HIV prevalence over 10 years, over double the coverage level is required relative to what was needed to achieve the same reduction in HIV incidence in that setting. To either reduce HIV incidence to less than 1% or HIV prevalence to less than 10% over 20 years, with all interventions combined, projections suggest that very high coverage levels of 74–85% are generally required for the higher prevalence settings of Tallinn and St. Petersburg, whereas lower coverage levels (23–34%) are needed in Dushanbe. Coverage requirements are robust to increased sexual HIV transmission, risk heterogeneity and like-with-like mixing, as well as to assuming a lower HIV acute phase cofactor or different injecting cessation rate.

CONCLUSION

The projections suggest that high but achievable coverage levels of NSP can result in large decreases (30%) in HIV incidence in settings with high HIV prevalence among PWID. Required coverage levels are much lower when interventions are combined or in lower prevalence settings. However, even when all three interventions are combined, the targets of reducing HIV incidence to less than 1% or prevalence to less than 10% in 20 years may be hard to achieve except in lower prevalence settings.

HIV care continuum among men who have sex with men and persons who inject drugs in India: barriers to successful engagement

BACKGROUND

We characterize the human immunodeficiency virus (HIV) care continuum for men who have sex with men (MSM) and persons who inject drugs (PWID) across India.

METHODS

We recruited 12 022 MSM and 14 481 PWID across 26 Indian cities, using respondent-driven sampling (September 2012 to December 2013). Participants were aged ≥18 years and either self-identified as male and reported sex with a man in the prior year (MSM) or reported injection drug use in the prior 2 years (PWID). Correlates of awareness of HIV-positive status were characterized using multilevel logistic regression.

RESULTS

A total of 1146 MSM were HIV infected, of whom a median of 30% were aware of their HIV-positive status, 23% were linked to care, 22% were retained before antiretroviral therapy (ART), 16% had started ART, 16% were currently receiving ART, and 10% had suppressed viral loads. There was site variability (awareness range, 0%-90%; suppressed viral load range, 0%-58%). A total of 2906 PWID were HIV infected, of whom a median of 41% were aware, 36% were linked to care, 31% were retained before ART, 20% had started ART, 18% were currently receiving ART, and 15% had suppressed viral loads. Similar site variability was observed (awareness range: 2%-93%; suppressed viral load range: 0%-47%). Factors significantly associated with awareness were region, older age, being married (MSM) or female (PWID), use of other services (PWID), more lifetime sexual partners (MSM), and needle sharing (PWID). Ongoing injection drug use (PWID) and alcohol use (MSM) were associated with lower awareness.

CONCLUSIONS

In this large sample, the major barrier to HIV care engagement was awareness of HIV-positive status. Efforts should focus on linking HIV testing to other essential services.

CLINICAL TRIALS REGISTRATION

NCT01686750.

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.

Potential bias due to outcome-related loss to follow-up in cohort studies on incidence of drug injection: systematic review and meta-analysis

AIMS

A systematic review and meta-analysis were conducted to synthesize results from cohort studies on initiation into drug injection among vulnerable populations, to quantify heterogeneity in the estimated incidence rates of drug injection and to identify potential sources of heterogeneity and bias.

METHODS

MEDLINE, EMBASE, PsycINFO and LILACS were searched for relevant studies published between 1980 and 2012. Investigators independently reviewed studies for inclusion, retrieved information on baseline population characteristics and follow-up features and assessed study quality. Study-specific incidence rates of drug injection were calculated as the number of new injectors divided by the person-years at risk. The I(2) statistic was used to quantify heterogeneity in incidence rates across studies, and random-effects meta-regression models were used to identify determinants of heterogeneity and bias.

RESULTS

Nine cohorts totalling 1843 participants met the inclusion criteria, with individual sample sizes of 70-415 participants and follow-up lengths of 6 months-3.4 years. The incidence of drug injection varied widely, from 2.1 to 24.2 cases per 100 person-years. The strong between-study heterogeneity (I(2)  = 90%, P<0.001) was reduced significantly after accounting for the different follow-up lengths (I(2)  = 17%, P = 0.30), with a 57% (95% confidence interval 46-66%) decrease in the pooled incidence of drug injection per 1-year increase in average follow-up.

CONCLUSIONS

The incidence of drug injection decreases sharply with increasing follow-up length in cohort studies on drug injection initiation. Low retention rates and potential for downward selection bias in cohort studies on drug injection initiation are caused primarily by greater loss to follow-up among individuals at higher risk of starting injection, compared with other participants.

Dose-response relationship between methadone dose and adherence to antiretroviral therapy among HIV-positive people who use illicit opioids

BACKGROUND AND AIMS

For HIV-positive individuals who use illicit opioids, engagement in methadone maintenance therapy (MMT) can contribute to improved HIV treatment outcomes. However, to our knowledge, the role of methadone dosing in adherence to antiretroviral therapy (ART) has not yet been investigated. We sought to examine the relationship between methadone dose and ART adherence among a cohort of people who use illicit opioids.

DESIGN AND SETTING

We used data from the AIDS Care Cohort to Evaluate Access to Survival Services (ACCESS) study, an ongoing prospective observational cohort of HIV-positive people who use illicit drugs in Vancouver, Canada, linked confidentially to comprehensive HIV treatment data in a setting of universal no-cost medical care, including medications. We evaluated the longitudinal relationship between methadone dose and the likelihood of ≥ 95% adherence to ART among ART-exposed participants during periods of engagement in MMT.

PARTICIPANTS

Two hundred and ninety-seven ART-exposed individuals on MMT were recruited between December 2005 and May 2013 and followed for a median of 42.1 months.

MEASUREMENTS

We measured methadone dose at ≥ 100 versus < 100 mg/day and the likelihood of ≥ 95% adherence to ART.

FINDINGS

In adjusted generalized estimating equation (GEE) analyses, MMT dose ≥ 100 mg/day was associated independently with optimal adherence to ART [adjusted odds ratio (AOR) = 1.38; 95% confidence interval (CI) = 1.08-1.77). In a subanalysis, we observed a dose-response relationship between increasing MMT dose and ART adherence (AOR = 1.06 per 20 mg/day increase, 95% CI = 1.00-1.12).

CONCLUSION

Among HIV-positive individuals in methadone maintenance therapy, those receiving higher doses of methadone (≥ 100 mg/day) are more likely to achieve ≥ 95% adherence to antiretroviral therapy than those receiving lower doses.

Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial

BACKGROUND

Methadone is an effective treatment for opioid dependence. When people who are receiving methadone maintenance treatment for opioid dependence are incarcerated in prison or jail, most US correctional facilities discontinue their methadone treatment, either gradually, or more often, abruptly. This discontinuation can cause uncomfortable symptoms of withdrawal and renders prisoners susceptible to relapse and overdose on release. We aimed to study the effect of forced withdrawal from methadone upon incarceration on individuals' risk behaviours and engagement with post-release treatment programmes.

METHODS

In this randomised, open-label trial, we randomly assigned (1:1) inmates of the Rhode Island Department of Corrections (RI, USA) who were enrolled in a methadone maintenance-treatment programme in the community at the time of arrest and wanted to remain on methadone treatment during incarceration and on release, to either continuation of their methadone treatment or to usual care--forced tapered withdrawal from methadone. Participants could be included in the study only if their incarceration would be more than 1 week but less than 6 months. We did the random assignments with a computer-generated random permutation, and urn randomisation procedures to stratify participants by sex and race. Participants in the continued-methadone group were maintained on their methadone dose at the time of their incarceration (with dose adjustments as clinically indicated). Patients in the forced-withdrawal group followed the institution's standard withdrawal protocol of receiving methadone for 1 week at the dose at the time of their incarceration, then a tapered withdrawal regimen (for those on a starting dose >100 mg, the dose was reduced by 5 mg per day to 100 mg, then reduced by 3 mg per day to 0 mg; for those on a starting dose >100 mg, the dose was reduced by 3 mg per day to 0 mg). The main outcomes were engagement with a methadone maintenance-treatment clinic after release from incarceration and time to engagement with methadone maintenance treatment, by intention-to-treat and as-treated analyses, which we established in a follow-up interview with the participants at 1 month after their release from incarceration. Our study paid for 10 weeks of methadone treatment after release if participants needed financial help. This trial is registered with ClinicalTrials.gov, number NCT01874964.

FINDINGS

Between June 14, 2011, and April 3, 2013, we randomly assigned 283 prisoners to our study, 142 to continued methadone treatment, and 141 to forced withdrawal from methadone. Of these, 60 were excluded because they did not fit the eligibility criteria, leaving 114 in the continued-methadone group and 109 in the forced-withdrawal group (usual care). Participants assigned to continued methadone were more than twice as likely than forced-withdrawal participants to return to a community methadone clinic within 1 month of release (106 [96%] of 110 in the continued-methadone group compared with 68 [78%] of 87 in the forced-withdrawal group; adjusted hazard ratio [HR] 2·04, 95% CI 1·48-2·80). We noted no differences in serious adverse events between groups. For the continued-methadone and forced-withdrawal groups, the number of deaths were one and zero, non-fatal overdoses were one and two, admissions to hospital were one and four; and emergency-room visits were 11 and 16, respectively.

INTERPRETATION

Although our study had several limitations--eg, it only included participants incarcerated for fewer than 6 months, we showed that forced withdrawal from methadone on incarceration reduced the likelihood of prisoners re-engaging in methadone maintenance after their release. Continuation of methadone maintenance during incarceration could contribute to greater treatment engagement after release, which could in turn reduce the risk of death from overdose and risk behaviours.

FUNDING

National Institute on Drug Abuse and the Lifespan/Tufts/Brown Center for AIDS Research from the National Institutes of Health.

Opioid use and risk of liver fibrosis in HIV/hepatitis C virus-coinfected patients in Canada

OBJECTIVES

Opioid use and opioid-related mortality have increased dramatically since the 1990s in North America. The effect of opioids on the liver is incompletely understood. Some studies have suggested that opioids cause liver damage and others have failed to show any harm. HIV/hepatitis C virus (HCV)-coinfected persons may be particularly vulnerable to factors increasing liver fibrosis. We aimed to describe opioid use in an HIV/HCV-coinfected population in Canada and to estimate the association between opioid use and liver fibrosis.

METHODS

We conducted a cross-sectional descriptive analysis of the Canadian Co-infection Cohort Study data to characterize opioid use. We then conducted a longitudinal analysis to assess the average change in aspartate aminotransferase-to-platelet ratio index (APRI) score associated with opioid use using a generalized estimating equation with linear regression. We assessed the progression to significant liver fibrosis (APRI ≥ 1.5) associated with opioid use with pooled logistic regression.

RESULTS

In the 6 months preceding cohort entry, 32% of the participants had received an opioid prescription, 28% had used opioids illicitly and 18% had both received a prescription and used opioids illicitly. Neither prescribed nor illicit opioid use was associated with a change in the median APRI score [exp(β) 0.99 (95% confidence interval (CI) 0.82, 1.12) and exp(β) 0.95 (95% CI 0.81, 1.10), respectively] or with faster progression to liver fibrosis [hazard odds ratio (HOR) 1.20 (95% CI 0.73, 1.67) and HOR 1.09 (95% CI 0.63, 1.55), respectively].

CONCLUSIONS

Although opioids were commonly used both legally and illegally in our cohort, we were unable to demonstrate a negative impact on liver fibrosis progression.

Impact of incarceration on rates of methadone use in a community recruited cohort of injection drug users

BACKGROUND

Despite barriers to its use in many settings, opioid agonist therapy with methadone has become the standard of care for treating opioid (e.g. heroin) use disorder. Since people with opioid use disorders have an increased incidence of incarceration, we undertook the present study to evaluate the association between incarceration and methadone maintenance therapy among a cohort of injection drug users in a Canadian setting.

METHODS

A cohort of people who inject drugs was prospectively followed between May 1996 and May 2013 in Vancouver, Canada. We investigated the relationship between recent incarceration and methadone use using multivariate generalized estimating equation (GEE) logistic regression analysis.

RESULTS

Overall, 2758 individuals were recruited during the study period and followed for a median of 64 (interquartile range: 23-106) months. After adjusting for various potential confounders in the multivariate GEE model, being incarcerated remained independently associated with a lower likelihood of having received methadone treatment (Adjusted Odds Ratio: 0.87, 95% confidence interval: 0.81-0.93).

CONCLUSIONS

Our study demonstrates that incarceration was independently associated with a significantly lower likelihood of being on methadone. Given the role of methadone in reducing the harms of heroin use, including drug acquisitive crime and recidivism, these data suggest a need to scale-up methadone provision for incarcerated injection drug users.

Messaging to Increase Public Support for Naloxone Distribution Policies in the United States: Results from a Randomized Survey Experiment

Background

Barriers to public support for naloxone distribution include lack of knowledge, concerns about potential unintended consequences, and lack of sympathy for people at risk of overdose.

Methods

A randomized survey experiment was conducted with a nationally-representative web-based survey research panel (GfK KnowledgePanel). Participants were randomly assigned to read different messages alone or in combination: 1) factual information about naloxone; 2) pre-emptive refutation of potential concerns about naloxone distribution; and 3) a sympathetic narrative about a mother whose daughter died of an opioid overdose. Participants were then asked if they support or oppose policies related to naloxone distribution. For each policy item, logistic regression models were used to test the effect of each message exposure compared with the no-exposure control group.

Results

The final sample consisted of 1,598 participants (completion rate: 72.6%). Factual information and the sympathetic narrative alone each led to higher support for training first responders to use naloxone, providing naloxone to friends and family members of people using opioids, and passing laws to protect people who administer naloxone. Participants receiving the combination of the sympathetic narrative and factual information, compared to factual information alone, were more likely to support all policies: providing naloxone to friends and family members (OR: 2.0 [95% CI: 1.4 to 2.9]), training first responders to use naloxone (OR: 2.0 [95% CI: 1.2 to 3.4]), passing laws to protect people if they administer naloxone (OR: 1.5 [95% CI: 1.04 to 2.2]), and passing laws to protect people if they call for medical help for an overdose (OR: 1.7 [95% CI: 1.2 to 2.5]).

Conclusions

All messages increased public support, but combining factual information and the sympathetic narrative was most effective. Public support for naloxone distribution can be improved through education and sympathetic portrayals of the population who stands to benefit from these policies.

Navigating the poverty of heroin addiction treatment and recovery opportunity in Kenya: access work, self-care and rationed expectations

Drawing on the analyses of qualitative interview accounts of people who inject heroin in Kenya, we describe the narration of addiction treatment access and recovery desire in conditions characterised by a 'poverty of drug treatment opportunity'. We observe the performance of addiction recovery narrative in the face of heavy social constraints limiting access to care. Fee-based residential rehabilitation ('rehab') is the only treatment locally available and inaccessible to most. Its recovery potential is doubted, given normative expectations of relapse. Treating drug use is a product of tightly bounded agency. Individuals enact strategies to maximise their slim chances of treatment access ('access work'), develop self-care alternatives when these fail to materialise and ration their care expectations. The use of rehab as a primary means of respite and harm reduction rather than recovery and the individuation of care in the absence of an enabling recovery environment are key characteristics of drug treatment experience. The recent incorporation of 'harm reduction' into policy discourses may trouble the primacy of recovery narrative in addiction treatment and in how treatment desires are voiced. The diversification of drug treatments in combination with social interventions enabling their access are fundamental.

Expanding substance use treatment options for HIV prevention with buprenorphine-naloxone: HIV Prevention Trials Network 058

BACKGROUND

Injection opioid use plays a significant role in the transmission of HIV infection in many communities and several regions of the world. Access to evidence-based treatments for opioid use disorders is extremely limited.

METHODS

HIV Prevention Trials Network 058 (HPTN 058) was a randomized controlled trial designed to compare the impact of 2 medication-assisted treatment (MAT) strategies on HIV incidence or death among opioid-dependent people who inject drugs (PWID). HIV-negative opioid-dependent PWID were recruited from 4 communities in Thailand and China with historically high prevalence of HIV among PWID. A total of 1251 participants were randomly assigned to either (1) a 1-year intervention consisting of 2 opportunities for a 15-day detoxification with buprenorphine/naloxone (BUP/NX) combined with up to 21 sessions of behavioral drug and risk counseling [short-term medication-assisted treatment (ST-MAT)] or (2) thrice-weekly dosing for 48 weeks with BUP/NX and up to 21 counseling sessions [long-term medication-assisted treatment (LT-MAT)] followed by dose tapering. All participants were followed for 52 weeks after treatment completion to assess durability of impact.

RESULTS

Although the study was stopped early due to lower than expected occurrence of the primary end points, sufficient data were available to assess the impact of the interventions on drug use and injection-related risk behavior. At week 26, 22% of ST-MAT participants had negative urinalyses for opioids compared with 57% in the LT-MAT (P < 0.001). Differences disappeared in the year after treatment: at week 78, 35% in ST-MAT and 32% in the LT-MAT had negative urinalyses. Injection-related risk behaviors were significantly reduced in both groups after randomization.

CONCLUSIONS

Participants receiving BUP/NX 3 times weekly were more likely to reduce opioid injection while on active treatment. Both treatment strategies were considered safe and associated with reductions in injection-related risk behavior. These data support the use of thrice-weekly BUP/NX as a way to reduce exposure to HIV risk. Continued access to BUP/NX may be required to sustain reductions in opioid use.

Comparison of outcomes after 3-month methadone maintenance treatment between heroin users with and without HIV infection: a 3-month follow-up study

Background

The aim of this study was to compare the changes in primary (heroin use-related) and secondary (depressive symptoms and quality of life, QOL) outcome indicators of 3-month methadone maintenance treatment (MMT) between heroin users with and without HIV infection.

Methods

A total of 242 intravenous heroin-dependent individuals (30 with and 212 without HIV infection) receiving MMT were recruited. Primary (severity of heroin dependence, harm caused by heroin use and current heroin use) and secondary (depressive symptoms and QOL) outcome indicators were determined before and after receiving 3-month MMT. Changes in primary and secondary outcome indicators between the two groups were compared using mixed-model analysis.

Results

Heroin users both with and without HIV infection showed significant improvement in three primary outcome indicators after 3-month MMT, and there was no difference in the changes of these primary outcome indicators between the two groups. However, improvements in depressive symptoms and the physical domain of QOL among HIV-infected heroin users were poorer than in those without HIV infection.

Conclusions

The results of this study indicated that heroin users with HIV infection did improve in the primary but not the secondary outcomes after 3-month MMT.

Increasing prevalence of HIV infection among first time clients in Italian drug treatment services - is it sexual transmission?

BACKGROUND

Over the last two decades, the proportion of people who inject drugs among newly reported HIV cases in Italy has been continuously declining. This trend is reflected in the prevalence of HIV infection among problem drug users followed in drug treatment services. We report nationwide trends in the prevalence of HIV and HCV among tested clients in charge to drug addiction services from 2005 to 2011.

METHODS

Data on the prevalence of HIV and HCV among drug users from public drug treatment services across Italy were collected and analyzed for the period from 2005 to 2011. Prevalence of HIV and HCV were compared between clients returning to treatment and those entering treatment for the first time, and by gender. Due to the high percentage of missing data, the "inverse probability weight" method was used. Trends in testing uptake were also analysed.

RESULTS

A significant decrease of HIV and HCV prevalence is observed among all PDUs entering treatment (from 14.7% to 11.1% and from 61.6% to 50%, respectively, in 2005-2011). By contrast, among those entering the services for the first time, after an initial decline the prevalence of HIV infection steadily increased in both sexes, from 2.2% in 2009 to 5.3% in 2011. Self-reported injecting rates in this group decreased over time, and in 2011 the proportion reporting drug injecting was lower among new clients than in people returning to services (14.5 vs. 34.4%). We also observed a progressive and significant reduction in HIV and HCV testing in drug treatment services.

CONCLUSIONS

Changes in injection practice and type of drugs used, coupled with a concurrent reduction in HCV prevalence, do not support drug injection as the main explanation for an increased HIV transmission in people entering drug treatment services for the first time. While reductions in testing rates raise concerns over data quality, the possibility of increased sexual transmission needs to be considered.

Current and recent drug use intensifies sexual and structural HIV risk outcomes among female sex workers in the Russian Federation

BACKGROUND

Female sex workers (FSW) and people who inject drugs (PWID) are at high risk for HIV infection, with FSW-PWID at even greater risk. HIV-related research often focuses on the primary mode of transmission - sexual or parenteral transmission for FSW and PWID, respectively - with less known on how sex work and injection drug use (IDU) are collectively associated with the risk environment experienced by sex workers. We investigated this relationship among FSW in three Russian cities.

METHODS

In 2011, FSWs (N=754) in Tomsk, Krasnoyarsk, and Kazan were recruited via respondent-driven sampling and completed a survey and rapid HIV screening. Multivariable models evaluated the role of injection history (classified as active: last 6 months, former: prior to last 6 months, and never) with a set of sexual and structural HIV risk outcomes.

RESULTS

IDU was common: 11% actively injected drugs and 11% were former injectors. HIV infection was most prevalent among active injectors (AOR: 6.7; 95% CI: 2.4-18.9) and former injectors (AOR:4.5; 95%CI: 1.7-11.6), compared to non-injectors. Some 6-8% of non-injecting FSWs reported recent physical or sexual client violence and 23% police extortion. Compared to these non-injectors, active injecting was associated with unprotected anal sex (AOR: 2.8, 95%CI: 1.2-6.4), client violence (AOR: 7.3, 95%CI: 2.1-24.7), and police extortion (AOR: 3.0 95%CI: 1.5-5.9%). Self-reported sexual and structural risk outcomes were also more prevalent among active compared to former injectors; however, few differences existed between former and non-injectors.

CONCLUSIONS

FSW experience sexual, structural, and HIV risk outcomes and these risks are amplified for actively injecting FSWs. FSW who stopped injecting drugs demonstrated risk profiles closer to those of sex workers who had no history of injection. HIV prevention programs and outreach can provide opportunities to include harm reduction interventions and linkage to treatment for FSW to move FSWs towards lower risk environments.

Perceived barriers to utilise methadone maintenance therapy among male injection drug users in rural areas of southern Thailand

INTRODUCTION AND AIMS

Methadone maintenance therapy (MMT) has been proven to be effective and cost-effective in treating dependence on opioids. However, concerns remain that geographical, financial and other hidden barriers may hinder access to MMT, especially in rural areas where health services are limited. The objective of this study was to determine factors associated with utilisation of MMT by injection drug users (IDUs) living in Songkhla province.

DESIGN AND METHODS

A cross-sectional study among 159 IDUs in Songkhla province of southern Thailand was conducted. Participants were recruited using a snowball technique. Data were collected from July 2013 to January 2014 via face-to-face interviews.

RESULTS

Around one-forth (24.5%) of participants had difficulties travelling to MMT clinics because of the long distance, long travelling time and lack of a private vehicle. Twenty-four percent faced difficulties with the clinic's opening hours and 28% faced difficulties paying for the cost of travel. IDUs who utilised the MMT perceived risks of injection drug use differently compared with those who did not. Younger or Muslim IDUs were less likely to attend MMT. IDUs who perceived that MMT was effective were more likely to utilise MMT.

DISCUSSION AND CONCLUSIONS

Physical accessibility, affordability and acceptability play an essential role in MMT utilisation. Developing alternatives that reduce the travelling time, costs for IDUs and more convenient operation hours to suit their lifestyles may increase the utilisation of MMT. Intensive consultation before starting MMT is highly recommended.

Influence of different drugs on HIV risk in people who inject: systematic review and meta-analysis

AIMS

To assess systematically the risk of HIV acquisition by type of drug injected across different settings.

METHODS

A systematic review and meta-analysis were conducted. Databases were searched for studies of HIV incidence in people who inject different drugs (PWID). Pooled HIV incidence rate ratio (IRR) was used to compare HIV risk between injecting and not-injecting a given drug, when possible, or otherwise with those reported not to have injected the substance. Pooled estimates of crude IRR were derived using random-effects models. Variations in IRR were assessed in subgroup analyses, by drug and geographical region.

RESULTS

Of 5779 studies screened, 15 were included. HIV incidence was reported for people injecting cocaine (eight: North America, Europe), amphetamine-type stimulants (ATS) (four: Western and Eastern Europe, Asia), heroin (11: all settings), opiate-stimulants (four: North America, Western and Eastern Europe) and opiates-sedatives (five: Europe, Asia). HIV risk in cocaine injectors was 3.6 times 95% confidence interval (CI) = 2.8-4.7, I(2)  = 0%; n = 4) that of non-injectors and 3.0 for ATS injectors (95% CI = 2.2-4.1, I(2)  = 0%; n = 2). Higher sexual risk was reported in cohorts injecting stimulants. Compared to not-injecting, HIV IRR was 2.8 (95% CI = 1.7-4.7, I(2)  = 77%; n=6) for all heroin injectors and 3.5 (95% CI = 2.3-5.2, I(2)  = 40%; n=5) for heroin injectors in Asia and Europe.

CONCLUSION

The risk of HIV acquisition in people who inject drugs appears to vary by drug type but differences are not statistically significant, precluding conclusive grading of risk.

Is the promise of methadone Kenya's solution to managing HIV and addiction? A mixed-method mathematical modelling and qualitative study

BACKGROUND AND OBJECTIVES

Promoted globally as an evidence-based intervention in the prevention of HIV and treatment of heroin addiction among people who inject drugs (PWID), opioid substitution treatment (OST) can help control emerging HIV epidemics among PWID. With implementation in December 2014, Kenya is the third Sub-Saharan African country to have introduced OST. We combine dynamic mathematical modelling with qualitative sociological research to examine the 'promise of methadone' to Kenya.

METHODS, SETTING AND PARTICIPANTS

We model the HIV prevention impact of OST in Nairobi, Kenya, at different levels of intervention coverage. We draw on thematic analyses of 109 qualitative interviews with PWID, and 43 with stakeholders, to chart their narratives of expectation in relation to the promise of methadone.

RESULTS

The modelled impact of OST shows relatively slight reductions in HIV incidence (5-10%) and prevalence (2-4%) over 5 years at coverage levels (around 10%) anticipated in the planned roll-out of OST. However, there is a higher impact with increased coverage, with 40% coverage producing a 20% reduction in HIV incidence, even when accounting for relatively high sexual transmissions. Qualitative findings emphasise a culture of 'rationed expectation' in relation to access to care and a 'poverty of drug treatment opportunity'. In this context, the promise of methadone may be narrated as a symbol of hope-both for individuals and community-in relation to addiction recovery.

CONCLUSIONS

Methadone offers HIV prevention potential, but there is a need to better model the effects of sexual HIV transmission in mediating the impact of OST among PWID in settings characterised by a combination of generalised and concentrated epidemics. We find that individual and community narratives of methadone as hope for recovery coexist with policy narratives positioning methadone primarily in relation to HIV prevention. Our analyses show the value of mixed methods approaches to investigating newly-introduced interventions.

Opioid substitution therapy is associated with increased detection of hepatitis C virus infection: a 15-year observational cohort study

BACKGROUND

Strategies are needed to enhance screening of hepatitis C virus (HCV) infection among people who inject drugs to improve engagement in HCV treatment, and stem the growing burden of HCV-related morbidity and mortality.

METHODS

We linked routinely collected data on enrolment in opioid substitution therapy (OST) and HCV notifications. We calculated rates of incident HCV notifications, and compared rates in and out of OST.

RESULTS

Following adjustment for sex, age and calendar period, rates of incident HCV notification were significantly higher during periods of OST, compared to periods out of OST (adjusted incident rate ratio: 1.91; 95% confidence interval: 1.86, 1.97). This effect was seen across multiple treatment periods.

CONCLUSIONS

HCV screening in OST settings increases detection of HCV infection among people who inject drugs.

Differential risk factors for HIV drug and sex risk-taking among non-treatment-seeking hospitalized injection drug users

Injection drug users (IDUs) are at increased risk of contracting HIV. From a clinical trial assessing an intervention to enhance the linkage of hospitalized patients to opioid treatment after discharge, we conducted multivariate analysis of baseline data from hospitalized IDUs with a history of opioid dependence (n = 104) to identify differences in factors predicting HIV drug and sex risk behaviors. Factors significantly associated with HIV drug risk were being non-Hispanic Caucasian and recent cocaine use. Being female, binge drinking, and poorer mental health were significantly associated with higher sex risk. Because factors predicting HIV sex risk behaviors differ from those predicting HIV drug risk, interventions aimed at specific HIV risks should have different behavioral and substance use targets.

Tailored combination prevention packages and PrEP for young key populations

INTRODUCTION

Young key populations, defined in this article as men who have sex with men, transgender persons, people who sell sex and people who inject drugs, are at particularly high risk for HIV. Due to the often marginalized and sometimes criminalized status of young people who identify as members of key populations, there is a need for HIV prevention packages that account for the unique and challenging circumstances they face. Pre-exposure prophylaxis (PrEP) is likely to become an important element of combination prevention for many young key populations.

OBJECTIVE

In this paper, we discuss important challenges to HIV prevention among young key populations, identify key components of a tailored combination prevention package for this population and examine the role of PrEP in these prevention packages.

METHODS

We conducted a comprehensive review of the evidence to date on prevention strategies, challenges to prevention and combination prevention packages for young key populations. We focused specifically on the role of PrEP in these prevention packages and on young people under the age of 24, and 18 in particular.

RESULTS AND DISCUSSION

Combination prevention packages that include effective, acceptable and scalable behavioural, structural and biologic interventions are needed for all key populations to prevent new HIV infections. Interventions in these packages should meaningfully involve beneficiaries in the design and implementation of the intervention, and take into account the context in which the intervention is being delivered to thoughtfully address issues of stigma and discrimination. These interventions will likely be most effective if implemented in conjunction with strategies to facilitate an enabling environment, including increasing access to HIV testing and health services for PrEP and other prevention strategies, decriminalizing key populations' practices, increasing access to prevention and care, reducing stigma and discrimination, and fostering community empowerment. PrEP could offer a highly effective, time-limited primary prevention for young key populations if it is implemented in combination with other programs to increase access to health services and encourage the reliable use of PrEP while at risk of HIV exposure.

CONCLUSIONS

Reductions in HIV incidence will only be achieved through the implementation of combinations of interventions that include biomedical and behavioural interventions, as well as components that address social, economic and other structural factors that influence HIV prevention and transmission.

Cost-effectiveness analysis of brief and expanded evidence-based risk reduction interventions for HIV-infected people who inject drugs in the United States

AIMS

Two behavioral HIV prevention interventions for people who inject drugs (PWID) infected with HIV include the Holistic Health Recovery Program for HIV+ (HHRP+), a comprehensive evidence-based CDC-supported program, and an abbreviated Holistic Health for HIV (3H+) Program, an adapted HHRP+ version in treatment settings. We compared the projected health benefits and cost-effectiveness of both programs, in addition to opioid substitution therapy (OST), to the status quo in the U.S.

METHODS

A dynamic HIV transmission model calibrated to epidemic data of current US populations was created. Projected outcomes include future HIV incidence, HIV prevalence, and quality-adjusted life years (QALYs) gained under alternative strategies. Total medical costs were estimated to compare the cost-effectiveness of each strategy.

RESULTS

Over 10 years, expanding HHRP+ access to 80% of PWID could avert up to 29,000 HIV infections, or 6% of the projected total, at a cost of $7,777/QALY gained. Alternatively, 3H+ could avert 19,000 infections, but is slightly more cost-effective ($7,707/QALY), and remains so under widely varying effectiveness and cost assumptions. Nearly two-thirds of infections averted with either program are among non-PWIDs, due to reduced sexual transmission from PWID to their partners. Expanding these programs with broader OST coverage could avert up to 74,000 HIV infections over 10 years and reduce HIV prevalence from 16.5% to 14.1%, but is substantially more expensive than HHRP+ or 3H+ alone.

CONCLUSIONS

Both behavioral interventions were effective and cost-effective at reducing HIV incidence among both PWID and the general adult population; however, 3H+, the economical HHRP+ version, was slightly more cost-effective than HHRP+.

Associations of substance use patterns with attempted suicide among persons who inject drugs: can distinct use patterns play a role?

BACKGROUND

While the elevated risk of suicide attempt among persons who inject drugs (PWID) is well documented, whether use of different substances is associated with varying degrees of risk remains unclear. We sought to examine the associations between substance use patterns and attempted suicide in a prospective cohort of PWID in Montreal, Canada.

METHODS

Between 2004 and 2011, participants completed an interviewer-administered questionnaire eliciting information on socio-demographics, substance use patterns, related behaviors, and mental health markers. Generalized estimating equations were used to model the relationship between self-reported use of six common substances (cocaine, amphetamine, opioids, sedative-hypnotics, cannabis and alcohol), associated patterns of use (chronic, occasional and none), and a recent (past six-month) suicide attempt.

RESULTS

At baseline, of 1240 participants (median age: 39.1, 83.7% male), 71 (5.7%) reported a recent suicide attempt. Among 5621 observations collected during follow-up, 221 attempts were reported by 143 (11.5%) participants. In multivariate analyses adjusting for socio-demographics and psychosocial stressors, among primary drugs of abuse, chronic [adjusted odds ratio (AOR): 1.97] and occasional (AOR: 1.92) cocaine use, and chronic amphetamine use (AOR: 1.96) were independently associated with attempted suicide. Among co-used substances, chronic sedative-hypnotic use was independently associated with an attempt (AOR: 2.29). No statistically significant association was found for the remaining substances.

CONCLUSION

Among PWID at high risk of attempted suicide, stimulant users appear to constitute a particularly vulnerable sub-group. While the mechanisms underlying these associations remain to be elucidated, findings suggest that stimulant-using PWID should constitute a prime focus of suicide prevention efforts.

Global HIV epidemiology: A guide for strategies in prevention and care

Global trends in HIV incidence are estimated typically by serial prevalence surveys in selected sentinel populations or less often in representative population samples. Incidence estimates are often modeled because cohorts are costly to maintain and are rarely representative of larger populations. From global trends, we can see reason for cautious optimism. Downward trends in generalized epidemics in Africa, concentrated epidemics in persons who inject drugs (PWID), some female sex worker cohorts, and among older men who have sex with men (MSM) have been noted. However, younger MSM and those from minority populations, as with black MSM in the United States, show continued transmission at high rates. Among the many HIV prevention strategies, current efforts to expand testing, linkage to effective care, and adherence to antiretroviral therapy are known as "treatment as prevention" (TasP). A concept first forged for the prevention of mother to child transmission, TasP generates high hopes that persons treated early will derive considerable clinical benefits and that lower infectiousness will reduce transmission in communities. With the global successes of risk reduction for PWID, we have learned that reducing marginalization of the at-risk population, implementation of nonjudgmental and pragmatic sterile needle and syringe exchange programs, and offering of opiate substitution therapy to help persons eschew needle use altogether can work to reduce the HIV epidemic. Never has the urgency of stigma reduction and guarantees of human rights been more urgent; a public health approach to at-risk populations requires that to avail themselves of prevention services and they must feel welcomed.

Psychiatric services and prescription fills among veterans with serious mental illness in methadone maintenance treatment

OBJECTIVE

Comorbidity and co-prescription patterns of people with serious mental illness in methadone maintenance may complicate their treatment and have not been studied. The goal of this study was to examine the care and characteristics of people with serious mental illness in methadone maintenance treatment nationally in the Veterans Health Administration (VHA).

METHODS

Using national VHA data from FY2012, bivariate and multiple logistic regression analyses were used to compare veterans in methadone maintenance treatment wo had a serious mental illness (schizophrenia, bipolar disorder, or major affective disorder) to patients in methadone maintenance treatment without serious mental illness and patients with serious mental illness who were not in methadone maintenance treatment.

RESULTS

Only a small fraction of patients with serious mental illness were receiving methadone maintenance treatment (0.65%), but a relatively large proportion in methadone maintenance treatment had a serious mental illness (33.2%). Compared to patients without serious mental illness, patients with serious mental illness in methadone maintenance treatment were more likely to have been homeless, to have had a recent psychiatric hospitalization, to be over 50% disabled, and to have had more fills for more classes of psychotropic drugs. Compared to other patients with serious mental illness, patients with serious mental illness in methadone maintenance treatment were more likely to have a drug abuse diagnosis and to reside in large urban areas.

CONCLUSIONS

One-third of patients in methadone maintenance treatment have serious mental illness and more frequent psychiatric comorbidity, and they are more likely to use psychiatric and general health services and fill more types of psychiatric prescriptions. Further study and clinical awareness of potential drug-drug interactions in this high medication and service using population are needed.

Geographic variability in HIV and injection drug use in Ukraine: implications for integration and expansion of drug treatment and HIV care

BACKGROUND

Ukraine has the highest HIV burden of any European country with much of the current HIV epidemic concentrated among people who inject drugs (PWIDs) and their sexual partners. Opiate substitution therapy (OST) is limited in Ukraine and expansion of OST is urgently needed to help stem the tide of the HIV epidemic.

METHODS

We accessed publicly available data in Ukraine in order to explore geographic variability with respect to prevalence of HIV, PWIDs and OST programmes.

RESULTS

The regions of Ukraine with the largest number of opioid dependent persons (the south and eastern portions of the country) correspond to the regions with the highest HIV prevalence and HIV incidence. The number of opioid PWIDs per 100,000 population as well as the number of all OST treatment slots per 100,000 varied significantly across the three HIV prevalence categories. Overall, the proportion of individuals receiving either methadone maintenance therapy (MMT) or buprenorphine maintenance therapy (BMT) was quite low: average across categories: 7.3% and 0.4%, respectively. Additionally, less than half of OST patients receiving MMT or BMT were HIV positive patients.

CONCLUSION

There is significant geographic variability in both numbers of HIV positive individuals and numbers of PWIDs across Ukraine, however, there may be a more concentrated epidemic among PWIDs in many regions of the country. Scale up of addiction treatment for PWID, especially OST, can have a significant impact on preventing injection related morbidity, such as HIV and HCV infection. Ukraine can learn from the mistakes other nations have made in denying critical treatment opportunities to PWID.

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.

Effect of rapid HIV testing on HIV incidence and services in populations at high risk for HIV exposure: an equity-focused systematic review

OBJECTIVE

To assess the effects of rapid voluntary counselling and testing (VCT) for HIV on HIV incidence and uptake of HIV/AIDS services in people at high risk for HIV exposure.

DESIGN

Cochrane systematic review and meta-analysis.

DATA SOURCES

We searched PubMed, EMBASE, AIDSearch, LILACS, Global Health, Medline Africa, PsychInfo, CINAHL, Cochrane CENTRAL, Cochrane HIV/AIDS Group Specialized Register and grey literature from 1 January 2001 to 5 June 2014 without language restriction.

DATA SELECTION

We included controlled studies that compared rapid VCT with conventional testing among people at risk for HIV exposure.

DATA EXTRACTION

Two reviewers extracted data. We used Cochrane risk of bias tool and GRADE criteria: risk of bias, inconsistency, indirectness, imprecision and publication bias. For observational studies we used the Newcastle-Ottawa Scale. We used the PRISMA-Equity reporting guideline.

RESULTS

From 2441 articles, we included 8 randomised controlled trials and 5 observational studies. Rapid VCT was associated with a threefold increase in HIV-testing uptake (relative risk (RR)=2.95 95% CI 1.69 to 5.16) and a twofold increase in the receipt of test results (RR=2.14, 95% CI 1.08 to 4.24). Women accepted testing more often than men in rapid VCT arm, but no differences in effect for age or socioeconomic status. Observational studies also showed rapid VCT led to higher rates of uptake of testing. Heterogeneity was high. A cluster-randomised trial reported an 11% reduction in HIV incidence in intervention communities (RR=0.89, 95% CI=0.63 to 1.24) over 3 years trial.

CONCLUSIONS

Rapid VCT in health facilities and communities was associated with a large increase in HIV-testing uptake and receipt of results. This has implications for WHO guidelines. The routine use of rapid VCT may also help avoid human rights violations among marginalised populations where testing may occur without informed consent and where existing stigma may create barriers to testing.

The prescription of addiction medications after implementation of chronic care management for substance dependence in primary care

People with addictive disorders commonly do not receive efficacious medications. Chronic care management (CCM) is designed to facilitate delivery of effective therapies. Using data from the CCM group in a trial testing its effectiveness for addiction (N=282), we examined factors associated with the prescription of addiction medications. Among participants with alcohol dependence, 17% (95% CI 12.0-22.1%) were prescribed alcohol dependence medications. Among those with drug dependence, 9% (95% CI 5.5-12.6%) were prescribed drug dependence medications. Among those with opioids as a substance of choice, 15% (95% CI 9.3-20.9%) were prescribed opioid agonist therapy. In contrast, psychiatric medications were prescribed to 64% (95% CI 58.2-69.4%). Absence of co-morbid drug dependence was associated with prescription of alcohol dependence medications. Lower alcohol addiction severity and recent opioid use were associated with prescription of drug dependence medications. Better understanding of infrequent prescription of addiction medications, despite a supportive clinical setting, might inform optimal approaches to delivering addiction medications.

Association of opioid agonist therapy with lower incidence of hepatitis C virus infection in young adult injection drug users

IMPORTANCE

Injection drug use is the primary mode of transmission for hepatitis C virus (HCV) infection. Prior studies suggest opioid agonist therapy may reduce the incidence of HCV infection among injection drug users; however, little is known about the effects of this therapy in younger users.

OBJECTIVE

To evaluate whether opioid agonist therapy was associated with a lower incidence of HCV infection in a cohort of young adult injection drug users.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study conducted from January 3, 2000, through August 21, 2013, with quarterly interviews and blood sampling. We recruited young adult (younger than 30 years) injection drug users who were negative for anti-HCV antibody and/or HCV RNA.

EXPOSURES

Substance use treatment within the past 3 months, including non-opioid agonist forms of treatment, opioid agonist (methadone hydrochloride or buprenorphine hydrochloride) detoxification or maintenance therapy, or no treatment.

MAIN OUTCOMES AND MEASURES

Incident HCV infection documented with a new positive result for HCV RNA and/or HCV antibodies. Cumulative incidence rates (95% CI) of HCV infection were calculated assuming a Poisson distribution. Cox proportional hazards regression models were fit adjusting for age, sex, race, years of injection drug use, homelessness, and incarceration.

RESULTS

Baseline characteristics of the sample (n = 552) included median age of 23 (interquartile range, 20-26) years; 31.9% female; 73.1% white; 39.7% who did not graduate from high school; and 69.2% who were homeless. During the observation period of 680 person-years, 171 incident cases of HCV infection occurred (incidence rate, 25.1 [95% CI, 21.6-29.2] per 100 person-years). The rate ratio was significantly lower for participants who reported recent maintenance opioid agonist therapy (0.31 [95% CI, 0.14-0.65]; P = .001) but not for those who reported recent non-opioid agonist forms of treatment (0.63 [95% CI, 0.37-1.08]; P = .09) or opioid agonist detoxification (1.45 [95% CI, 0.80-2.69]; P = .23). After adjustment for other covariates, maintenance opioid agonist therapy was associated with lower relative hazards for acquiring HCV infection over time (adjusted hazard ratio, 0.39 [95% CI, 0.18-0.87]; P = .02).

CONCLUSIONS AND RELEVANCE

In this cohort of young adult injection drug users, recent maintenance opioid agonist therapy was associated with a lower incidence of HCV infection. Maintenance treatment with methadone or buprenorphine for opioid use disorders may be an important strategy to prevent the spread of HCV infection among young injection drug users.

The cost-effectiveness of harm reduction

HIV prevalence worldwide among people who inject drugs (PWID) is around 19%. Harm reduction for PWID includes needle-syringe programs (NSPs) and opioid substitution therapy (OST) but often coupled with antiretroviral therapy (ART) for people living with HIV. Numerous studies have examined the effectiveness of each harm reduction strategy. This commentary discusses the evidence of effectiveness of the packages of harm reduction services and their cost-effectiveness with respect to HIV-related outcomes as well as estimate resources required to meet global and regional coverage targets. NSPs have been shown to be safe and very effective in reducing HIV transmission in diverse settings; there are many historical and very recent examples in diverse settings where the absence of, or reduction in, NSPs have resulted in exploding HIV epidemics compared to controlled epidemics with NSP implementation. NSPs are relatively inexpensive to implement and highly cost-effective according to commonly used willingness-to-pay thresholds. There is strong evidence that substitution therapy is effective, reducing the risk of HIV acquisition by 54% on average among PWID. OST is relatively expensive to implement when only HIV outcomes are considered; other societal benefits substantially improve the cost-effectiveness ratios to be highly favourable. Many studies have shown that ART is cost-effective for keeping people alive but there is only weak supportive, but growing evidence, of the additional effectiveness and cost-effectiveness of ART as prevention among PWID. Packages of combined harm reduction approaches are highly likely to be more effective and cost-effective than partial approaches. The coverage of harm reduction programs remains extremely low across the world. The total annual costs of scaling up each of the harm reduction strategies from current coverage levels, by region, to meet WHO guideline coverage targets are high with ART greatest, followed by OST and then NSPs. But scale-up of all three approaches is essential. These interventions can be cost-effective by most thresholds in the short-term and cost-saving in the long-term.

Enhancing motivation within a rapid opioid substitution treatment feasibility RCT: a nested qualitative study

Background

Opioid substitution treatment (OST) has multiple benefits for heroin injectors and is an evidence-based major component of international treatment. The current qualitative study sought to explore participants’ attitudes to and reasons for participating in a feasibility randomised trial in primary care offering ‘same day’ OST (methadone) for injecting heroin users compared to usual care.

Methods

Twenty injecting heroin users (8 intervention and 12 controls; 16 males and 4 females) were interviewed; purposive sampling was used to select a maximum variation sample from those who agreed; and analysis used thematic methods.

Results

Motivation to join the trial included the need to secure treatment set against some ambivalence due to previous negative experiences of trying to obtain OST. Positive effects of securing methadone via the trial, included self-reported improvements in health and self-care; reduction in crime, stress and drug use. Completing the baseline questionnaires at recruitment appeared to enhance motivation for treatment for all participants. For some control participants, this motivation seemed to increase a sense of self-efficacy and cognitive dissonance generated was resolved by seeking treatment from their GP. Self-determination theory suggests that behaviour change may have been initiated during the recruitment appointment, resulting in an increased determination to seek treatment amongst control participants.

Conclusions

Taking part in the ‘script in a day’ trial enabled participants in the intervention arm to gain same-day access to methadone and reduce their drug use. For those in the control arm, completing the baseline questionnaires at recruitment appeared to create cognitive dissonance between their current health state and own aspirations, so increasing motivation for treatment. Over 50% obtained and were still in receipt of OST (methadone or buprenorphine) at the 3 month follow-up. We suggest that a regular ‘health evaluation’ for injecting heroin users not in treatment, paired with low-barrier access to treatment, may be a way of exploring this and encouraging more into obtaining OST more quickly and at the best time for them. This intervention should be delivered without pressure for change.

Clinical trial registration

This trial is registered with International Standard Randomised Controlled Trial Number Register: SCript In a Day for injecting drug users: feasibility trial: ISRCTN16846554.

Opioid substitution therapy protects against hepatitis C virus acquisition in people who inject drugs: the HITS-c study

OBJECTIVE

To estimate hepatitis C virus (HCV) incidence and identify associated risk and protective factors among people who inject drugs (PWID) in Sydney, New South Wales.

DESIGN, SETTING AND PARTICIPANTS

Community-based prospective observational study of serologically confirmed HCV antibody-negative PWID enrolled in six Sydney neighbourhoods located in three distinct regions between 10 November 2008 and 31 October 2011.

MAIN OUTCOME MEASURES

Serologically confirmed HCV incidence per person-years (py); and self-reported demographic and behavioural risk factors for HCV infection.

RESULTS

The overall incidence of HCV infection was 7.9/100 py. Risk factors independently associated with incident HCV infection were younger age (adjusted hazard ratio [AHR] for age < 27 years, 5.66; 95% CI, 1.69-18.95; P = 0.005) and daily or more frequent injecting (AHR, 4.06; 95% CI, 1.15-14.30; P = 0.03). Opioid substitution therapy (OST) was protective against HCV seroconversion and was associated with a reduced risk of incident infection among those who mainly injected heroin or other opioids (AHR for those not receiving OST while mainly injecting heroin or other opioids, 5.64; 95% CI, 1.30-24.42; P = 0.02).

CONCLUSION

The observed HCV incidence was substantially lower than the incidence of 30.8/100 py observed a decade earlier in a similar NSW-based cohort, suggesting a decline in HCV incidence among PWID. This is likely due to increased coverage of OST, combined with a probable decrease in the population of PWID.