Sex, drugs, and HIV: does methadone maintenance reduce drug use and risky sexual behavior?

The effect of methadone on depression among addicts: a systematic review and meta-analysis

Background

Opioids addiction and misuse are among the major problems in the world today. There have been several preliminary studies examining the effect of methadone on depression among addicts, however, these studies have reported inconsistent and even contradictory results. Therefore, the aim of the present study was to determine the effect of methadone on depression in addicts in Iran and around the world, using a meta-analysis approach.

Methods

This study was a systematic review and meta-analysis including articles published in the SID, MagIran, IranMedex, IranDoc, Cochrane, Embase, ScienceDirect, Scopus, PubMed and Web of Science databases were searched systematically to find articles published from 2006 to March 2019. Heterogeneity index was determined using the Cochran's test (Qc) and I². Considering heterogeneity of studies, the random effects model was used to estimate the standardized difference of mean score for depression. Subsequently, the level of depression reduction in Iran and worldwide in the intervention group before and after the testwas measured.

Results

A total of 19 articles met the inclusion criteria, and were therefore selected for this systematic review and meta-analysis. The sample size of the intervention group in the selected studies was 1948. According to the meta-analysis results, the mean depression score in the intervention group was 26.4 ± 5.6 and 18.4 ± 2.6 before and after intervention respectively, indicating the reducing effect of methadone on depression, and this difference was statistically significant (P < 0.01).

Conclusion

The results of the present study show that methadone significantly reduces depression in addicts. Therefore, regular methadone use can be part of a drug treatment plan.

Implementing Substance Abuse Intervention Services in New York City Sexually Transmitted Disease Clinics: Factors Promoting Interagency Collaboration

This report presents results of Project LINK, a Substance Abuse and Mental Health Services Administration (SAMHSA)-funded, 5-year collaboration (2007-2012) between New York City (NYC) health and NY State substance abuse disorder (SUD) agencies, an LGBT organization contractor, and multiple SUD, social service, and mental health referral agencies. LINK allowed the first ever SUD screening, brief intervention, and referrals to treatment (SBIRT) intervention services onsite in NYC Bureau of Sexually Transmitted Disease Control (BSTDC) clinics. Factors favoring collaboration were (a) joint recognition of substance abuse as an STD risk factor; (b) prior collaborations; (c) agreement on priority of BSTDC's mission and policies; (d) extensive SBIRT training, cross training on STDs; (e) a memorandum of agreement; and (f) mutual transparency of collaborative efforts, among others. LINK screened over 151,000 STD clinic patients and delivered brief interventions to 60% of positively screened patients and met a mandated follow-up target. Factors found to facilitate collaboration here may help screen prospective new health collaborations.

Sexual behaviors among methadone maintenance patients in a mountainous area in northern Vietnam

Background

Methadone maintenance treatment (MMT) improves patients’ ability to access HIV-related services and reduces needle sharing and other risky HIV-related behaviors. However, patients may continue to engage in risky sexual practices. In this study, we evaluate sexual behaviors of MMT patients in a mountainous province in Northern Vietnam.

Methods

We explored the health status, MMT and substance use history, and sexual practices of 241 male MMT patients in Tuyen Quang province. Health status was investigated using the EuroQOL-5 Dimensions-5 Levels (EQ-5D-5 L). Multivariate logistic regression was employed to assess associated factors.

Results

Most patients (66.4%) reported having at least one sexual partner within the previous twelve months. Most of these partners were spouses or primary partners (72.6%). About 8.3% of patients had casual partners, and 5.8% had visited sex workers; of those who engaged in casual sexual relationships, 90.9% reported using condoms. Current drug use and living in a remote area were associated with an increased odd of having two or more sexual partners, while anxiety or depression was associated with lower odds.

Conclusion

This study highlights a low proportion of having sexual risk behaviors among MMT patients in Vietnamese mountainous settings. Integrating education about safe sexual practices into MMT services, along with providing medical care and ensuring methadone treatment adherence, is an important component in HIV risk reduction for these patients who were at risk of unsafe sexual practices.

First Report of Gender Based Violence as a Deterrent to Methadone Access Among Females Who Use Heroin in Dar es Salaam, Tanzania

High prevalence of human immunodeficiency virus (HIV) among females who use drugs in Dar es Salaam, Tanzania, contrasts strikingly with their low enrollment in HIV risk reduction services such as methadone assisted therapy (MAT). We conducted a case-control study to examine factors associated with non-enrollment in MAT, with a focus on gender-based violence. We interviewed 202 female heroin users not enrolled in MAT as cases and 93 females enrolled in MAT. We fitted logistic regression models with MAT enrollment as the outcome of interest. The likelihood of MAT enrollment decreased upon being in a violent relationship [odds ratio (OR) 0.23; 95 % CI 0.11-0.40], with experience of discrimination by a healthcare provider (OR 0.11; 95 % CI 0.04-0.35), and having a partner who also uses drugs (OR 0.05; 95 % CI 0.01-0.26). The results indicate that violence and discrimination are major impediments to MAT enrollment, necessitating implementation of interventions to address them.

Prevalence and correlates of sexual risk behaviors among drug users in western China: implications for HIV transmission

The prevalence and correlates of sexual risk behaviors among drug users in western China and the implications for HIV transmission in this population are described. A cross-sectional survey of male drug users was conducted in methadone maintenance therapy clinics and detoxification centers in three western provinces of China between September 2009 and December 2010. Participants in the study completed a questionnaire about demographics, HIV/AIDS knowledge, drug use history, sexual risk behaviors, and other psychosocial variables. Factors associated with HIV sexual risk behaviors were identified by multiple logistic regression analysis. Of 1,304 drug users surveyed, nearly 54% never used condoms during sexual intercourse with a spouse or cohabitant, and this behavior was associated with coming from Chongqing (OR=1.86, p<0.05), being aged 36 and older (OR=5.03, p<0.05), being married or cohabiting (OR=1.68, p<0.05), having first taken drugs at age 30 and above (OR=1.80, p<0.05), and having received AIDS advice or detection from authorities in the past year (OR=1.95, p<0.05). Twenty-six percent had had sex with casual sexual partners in the past year, and this behavior was associated with being married or cohabiting (OR=0.30, p<0.05), first taking drugs at age 31 and above (OR=0.42, p<0.05), and receiving AIDS advice or HIV detection from authorities in the past year (OR=0.70, p<0.05). About 34% never used a condom when having sex with casual sexual partners, and this behavior was associated with coming from Guangxi (OR=2.81, p<0.05) or Chongqing (OR=2.73, p<0.05). Almost 14% had had commercial sex in the past year, and this behavior was associated with coming from Guangxi (OR=6.26, p<0.05) or Chongqing (OR=5.44, p<0.05) and having exchanged needles or received clean needles from the Needle Exchange Centers in the past year (OR=2.76, p<0.05). Nearly 23% had never used condoms when having commercial sex, and this behavior was associated with having received free condoms from authorities in the past year (OR=0.26, p<0.05). Sexual risk behaviors among drug users in Guangxi, Chongqing, and Xinjiang are common. Additional intervention strategies are needed to control the spread of HIV in this population.

Animal studies trigger new insights on the use of methadone maintenance

BACKGROUND

Although steady-state methadone (SSM) treatment is mainly used for opioid addiction, some clinical studies indicate that it also reduces cocaine abuse in opioid-dependent individuals.

OBJECTIVE/METHODS

To present evidence suggesting that SSM may be useful in the treatment of cocaine addiction without pre-existing opioid dependence. We review studies in animals investigating the effects of SSM on behaviors motivated by cocaine and on cocaine-induced alterations of genes expression in the rat brain.

CONCLUSION

SSM reduces cocaine intake, blocks cocaine seeking and normalizes expression of genes known to regulate cocaine seeking. These findings suggest that SSM could be an effective pharmacological agent to assist cocaine detoxification and prevention of relapse to cocaine abuse in individuals not co-dependent on opioid.

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.

The Cedar Project: methadone maintenance treatment among young Aboriginal people who use opioids in two Canadian cities

INTRODUCTION AND AIMS

The Cedar Project is a community-based study aiming to identify variables associated with ever being on methadone maintenance treatment (MMT) among young Aboriginal people using drugs and to discuss possible barriers to MMT in this population.

DESIGN AND METHODS

This is a prospective cohort study with recruitment by health-care providers, outreach, and word of mouth in Vancouver and Prince George. Participants included 605 Aboriginal participants who were age 14-30 years, reported illicit drug use in the month prior to enrolment, and provided written informed consent. Variables associated with ever being on MMT were analysed through χ(2) -testing and multivariate logistic regression, limited to people reporting opioid use (n = 397).

RESULTS

Less than half of participants reporting daily injection of opioids had ever been on MMT. In adjusted multivariate logistic regression analyses, older age [odds ratio (OR) 1.17; 95% confidence interval (CI) 1.08-1.28)]; female gender (OR 3.76; 95% CI 2.00-7.07); hepatitis C antibody positivity (OR 2.76; 95% CI 1.53-4.95); and daily opioid injection (OR 2.59; 95% CI 1.46-4.61) were positively associated with ever being on MMT. Weekly or more alcohol use (OR 0.43; 95% CI 0.21-0.87) was negatively associated with ever being on MMT.

DISCUSSION AND CONCLUSION

MMT access by young Aboriginal people is low. The associations between MMT use and other variables need further study to steer efforts directed at recruitment into MMT. The removal of barriers to MMT and inclusion of young Aboriginal people in the development of treatment programs based on Indigenous values are urgently required to help Aboriginal people who use drugs.

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.

Effects of heroin-assisted treatment on alcohol consumption: findings of the German randomized controlled trial

Alcohol has been suggested to be a risk factor for opioid-dependent patients in methadone maintenance treatment (MMT). Literature shows that MMT has limited effects on alcohol use. Nevertheless, a decrease in alcohol use was detected in the Swiss heroin-assisted treatment (HAT) study. In this article, we carry out an in-depth analysis of the German HAT trial with the aim of determining whether alcohol use was affected among patients undergoing HAT and MMT. Analysis was carried out using self-reported data on consumption units of alcohol used (CU), Addiction Severity Index composite scores (ASI CSs), and carbohydrate-deficient transferrin (CDT) measures. Results suggest significant reduction of CU and CDT in both groups, yet larger effects in the HAT group. ASI CS significantly decreased in the HAT but not in the MMT group. The greater benefit of HAT in reducing alcohol use may be due to the greater daily frequency of dispensing heroin coupled with a requirement of sobriety at each dosing occasion.

Sexual behavior and risks for HIV infection and transmission among male injecting drug users in Yunnan, China

OBJECTIVES

To analyze the risk factors, particularly sexual behaviors, associated with HIV infection, and to describe the risks for HIV transmission among male injecting drug users (IDUs) in China.

METHODS

A cross-sectional study of 314 IDUs in Yunnan Province was conducted. Information on demographics, HIV serostatus, and sexual and drug-using behaviors was collected.

RESULTS

HIV prevalence among the study subjects was 59.9%. HIV infection was associated with older age (> or = 27 years), early drug initiation (at < or = 20 years of age), and frequent injection (> or = once a day). Thirty-seven percent reported multiple sexual partners. Consistent condom use rates were lowest with regular partners (23.8%), followed by 42.5% with casual partners, and 57.3% with female sex workers. Ninety-eight percent of subjects received high 'HIV knowledge' scores. Few of the subjects who needed medical care sought it out.

CONCLUSIONS

Despite awareness of HIV, needle sharing and unprotected sex persist in the population, and the HIV prevalence is high. Further interventions should not only seek to educate but also to reduce high-risk behaviors.

Key findings from the WHO collaborative study on substitution therapy for opioid dependence and HIV/AIDS

AIMS

Opioid substitution treatment has been studied extensively in industrialized countries, but there are relatively few studies in developing/transitional countries. The aim of this study was to examine the effectiveness of opioid substitution treatment (OST) in less resourced countries.

DESIGN

Longitudinal cohort study.

SETTING

Purposively selected OST sites in Asia (China, Indonesia, Thailand), Eastern Europe (Lithuania, Poland, Ukraine), the Middle East (Iran) and Australia.

PARTICIPANTS

Seven hundred and twenty-six OST entrants.

MEASUREMENTS

Participants were interviewed at treatment entry, 3 and 6 months. Standardized instruments assessed drug use, treatment history, physical and psychological health, quality of life, criminal involvement, blood-borne virus (BBV) risk behaviours and prevalence of human immunodeficiency virus (HIV) and hepatitis C.

FINDINGS

Participants were predominantly male, aged in their early 30s and had attained similar levels of education. Seroprevalence rates for HIV were highest in Thailand (52%), followed by Indonesia (28%) and Iran (26%), and lowest in Australia (2.6%). Treatment retention at 6 months was uniformly high, averaging approximately 70%. All countries demonstrated significant and marked reductions in reported heroin and other illicit opioid use; HIV (and other BBV) exposure risk behaviours associated with injection drug users (IDU) and criminal activity, and demonstrated substantial improvement in their physical and mental health and general wellbeing over the course of the study.

CONCLUSIONS

OST can achieve similar outcomes consistently in a culturally diverse range of settings in low- and middle-income countries to those reported widely in high-income countries. It is associated with a substantial reduction in HIV exposure risk associated with IDU across nearly all the countries. Results support the expansion of opioid substitution treatment.

Contingency management reduces drug-related human immunodeficiency virus risk behaviors in cocaine-abusing methadone patients

AIM

Contingency management (CM) is efficacious in reducing drug use. This study examined whether CM also reduces human immunodeficiency virus (HIV) risk behaviors and if these effects are mediated by longest duration of abstinence achieved during treatment.

DESIGN

Data were analyzed from a subset of participants in a combined data set of three published randomized controlled trials of CM treatments.

SETTING

A community-based methadone maintenance clinic.

PARTICIPANTS

One-hundred and sixty-five cocaine-abusing methadone maintenance patients.

INTERVENTION

Participants received either standard methadone treatment or standard methadone treatment with CM for 3 months.

MEASUREMENTS

The HIV Risk Behavior Scale (HRBS) was administered prior to randomization to a study condition and 3 months after the study treatments ended. The primary objective indicator of drug use was longest duration of cocaine and opioid abstinence achieved during treatment.

FINDINGS

Relative to those assigned to standard care, participants receiving CM significantly decreased overall HIV risk behaviors and injection drug use risk behaviors. CM participants also achieved longer durations of consecutive cocaine and opioid abstinence during treatment. Duration of abstinence achieved mediated the relationship between treatment condition and HRBS difference scores.

CONCLUSIONS

These results suggest that CM treatment reduces HIV drug use risk behaviors in cocaine-abusing methadone maintenance patients.

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.

Gender differences in sex risk behaviors among Ukraine injection drug users

OBJECTIVE

To assess gender differences in drug and sex risk behaviors and evaluate predictors of HIV-related sex risk behaviors among heterosexual injection drug users (IDUs) in Ukraine.

DESIGN

Street-recruited IDUs from Kiev, Odessa, and Makeevka/Donesk, Ukraine.

METHODS

From June 2004 through November 2006, outreach workers recruited 1557 IDUs, including 526 from Kiev, 494 from Odessa, and 537 from Makeevka/Donesk. Participants were administered a standardized computer-assisted interview assessing HIV-related drug and sex risk behaviors, self-efficacy for practicing safe sex, and HIV knowledge.

RESULTS

Overall, 80% of the participants were sexually active in the 30-day period before their interview. They also engaged in high-risk sex behaviors during this brief 30-day window: 53% reported anal or vaginal sex without a condom, 27% had sex with more than 1 partner, 41% had an IDU sex partner, and 37% had an HIV-positive sex partner or a partner whose HIV status they did not know. Overall, women were at higher risk than men and were more likely to have been told they were HIV-positive.

CONCLUSION

The extremely high HIV prevalence rate in Ukraine and in this cohort, combined with their recent high-risk sex behaviors, forecasts not only a continuance of the epidemic in the region but an escalation.

The potential role of buprenorphine in the treatment of opioid dependence in HIV-infected individuals and in HIV infection prevention

Untreated opioid dependence is a major obstacle to the successful treatment and prevention of human immunodeficiency virus (HIV) infection. In this review, we examine the interwoven epidemics of HIV infection and opioid dependence and the emerging role of buprenorphine in improving HIV treatment outcomes among infected individuals, as well as its role in primary and secondary prevention. This article addresses some of the emerging issues about integrating buprenorphine treatment into HIV clinical care settings and the various strategies that must be considered. Specifically, it addresses the role of buprenorphine in improving HIV treatment outcomes through engagement in care, access to antiretroviral therapy and preventive therapies for opportunistic infections, and the potential benefits of and pitfalls in integrating buprenorphine into HIV clinical care settings. We discuss the key research questions regarding buprenorphine in the area of improving HIV treatment outcomes and prevention, including a review of published studies of buprenorphine and antiretroviral treatment and currently ongoing studies, and provide insight into and models for integrating buprenorphine into HIV clinical care settings. Dialogue among practitioners and policy makers in the HIV care and substance abuse communities will facilitate an effective expansion of buprenorphine and ensure that these beneficial outcomes are achieved.

Assessing alcohol and other drug problems (AOD) among sexually transmitted disease (STD) clinic patients with a modified CAGE-A: implications for AOD intervention services and STD prevention

The close link between alcohol and other drug abuse and STD morbidity and the positive impact of AOD intervention services in reducing STD morbidity, led the New York State Office of Alcoholism and Substance Abuse Services (OASAS) and the New York City Bureau of STD Control (BSTDC) to assess the prevalence of AOD problems among STD clinic patients. Assessing problematic AOD involvement among STD patients was of interest to BSTDC for STD prevention and to OASAS, for new AOD case-finding and early intervention. During fall, 2000, 100 STD patients in each of the 7 full-time BSTDC clinics in New York City were solicited in clinic waiting rooms; eligible patients were screened individually and anonymously with a modified CAGE-A (mCA). The mCA asks 4 questions about problematic AOD use "ever" (i.e., "lifetime") and currently (i.e., "in the past 30 days) rather than "in the past 12 months" of the CAGE and uses two or more "Yes" answers as a "positive" screen. The mCA also asks for age, sex, ethnicity, prior AOD treatment, and interest in an AOD referral. Only 2 of 704 eligible patients refused mCA screening, n = 702. Sixty percent were male, 87.7% Black and/or Hispanic, and 69%, <or=35 years old. Of the sample screened, 30.5% were "positive" on the "ever" and 16.5%, on "the past 30 days," mCA questions. 13.2% reported prior AOD treatment, 1.4% were in AOD treatment or about to start, and <1% wanted an AOD referral. Eight of 10 STD patients currently in AOD treatment screened positive on the "ever" mCA questions. The AOD prevalence rates observed here were deemed high since: 1) CAGE (and CAGE-A) data on general hospital and emergency room admissions showed positive screening rates of only 5-14 % and 2) only an estimated 6-7% of adults in New York have received any formal intervention with an AOD problem, less than half the rate found for treatment alone with the STD patients in this study. The results support implementing AOD screening and intervention services in STD clinics since an estimated 11,000 patients annually would screen positive but now are undetected and untreated. As AOD intervention services also can reduce risky sexual behavior, providing them could expand STD prevention services significantly. Policy, funding, and evaluation issues related to implementing AOD intervention services in STD and other public health clinics also are discussed.

Impact of drug treatment on subsequent sexual risk behavior in a multisite cohort of drug-using women: a report from the Women's Interagency HIV Study

BACKGROUND

The evidence that drug treatment programs are associated with changes in sexual behavior and, thus, have prevention benefits beyond addiction is inconclusive. We examined whether entry into drug treatment was associated with subsequent alterations in sexual behavior among a group of drug-using women.

METHODS

Data were collected semiannually via structured interviews over 8 years. Generalized estimating equations evaluated the relationship between self-reported drug treatment at each visit and sexual abstinence and consistent condom use in the subsequent 6-month period.

RESULTS

In this sample (N = 1,658; mean age, 37.3 years; 57.5% African American; 80.3% HIV positive; 49.6% crack/cocaine users), 40% reported being in a variety of drug treatment programs. Those undergoing drug treatment (vs. those not) were less likely to become sexually active (adjusted odds ratio [AOR], 0.83; 95% confidence interval [CI], 0.76-0.91); this association was unchanged when the frequency of attendance and number of different drug treatment programs were evaluated. Drug treatment was not associated with subsequent consistent condom, regardless of frequency of attendance, but involvement in at least three treatment programs was (AOR, 1.40; 95% CI, 1.00-1.97).

CONCLUSIONS

Additional efforts are needed to integrate effective sexual risk reduction programs into drug treatment settings; expanding access to different types of drug treatment modalities may be indicated.

Substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

REVIEWERS' CONCLUSIONS

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

Prisoners' attitudes toward Hepatitis B vaccination

BACKGROUND

Hepatitis B continues to be a substantial problem in the United States despite the existence of a safe and effective vaccine. Vaccination programs for inmates could reach many high-risk individuals but little is known about U.S. inmates' willingness to accept hepatitis B virus (HBV) vaccination while incarcerated. The goal of this study was to assess inmates' knowledge about hepatitis B and their willingness to accept hepatitis B vaccination while incarcerated.

METHODS

We interviewed 153 male and female inmates at the Rhode Island Department of Corrections (RIDOC) using a voluntary, anonymous survey.

RESULTS

Ninety-three percent of inmates said they would agree to receive the hepatitis B vaccine while incarcerated. More than half of the 30% who reported having risk factors for hepatitis B did not consider themselves to be at risk for hepatitis B and almost half (44%) of all inmates were not aware that hepatitis B can be transmitted through unprotected sex.

CONCLUSION

Hepatitis B vaccination programs in correctional settings are a public health priority and would be well received by the target population. Such programs would help protect the health of incarcerated persons and the communities to which they return.

Impact of Methadone Program Philosophy Changes on Early Treatment Outcomes

This paper describes the consequences of changing from methadone maintenance treatment focussed primarily on elimination of all illicit drug use and social reintegration to patient-centred care. Counselling (formerly mandatory) became optional, patients were retained in treatment despite continued illicit drug use, the ceiling on methadone doses was removed, patient input became a part of methadone prescribing and the number of patients in treatment more than doubled. Across three cohorts (before, during and after the program was redesigned) the mean daily dose of methadone increased (50.4 mg +/- 2.5, 72.6 mg +/- 2.4, 92.2 mg +/- 4.0, respectively). The number of physician visits increased linearly with cohort while the number of therapist visits was unchanged overall. Two-year treatment retention was not significantly different (73%, 69% and 67%, respectively). In all three cohorts there was a significant reduction in opioid and benzodiazepine use but not cocaine use over the first six months of treatment.