Heroin use and HIV risk-taking behaviour among women injecting drug users

This study compares drug use, injecting and sexual risk-taking behaviour among pregnant injecting drug users (IDUs) enrolled in methadone maintenance treatment (MMT), non-pregnant women IDUs enrolled in MMT and women IDUs not enrolled in treatment. There was no significant difference between pregnant IDUs enrolled in MMT and women IDUs not enrolled in treatment in terms of their injecting risk-taking behaviour. Both groups reported significantly higher levels of injecting risk-taking behaviour compared to (non-pregnant) women enrolled in MMT. Pregnant women enrolled in MMT reported a significantly lower methadone dose compared to non-pregnant women in MMT. There was a trend for pregnant women enrolled in MMT to report a higher level of heroin use compared to non-pregnant women in MMT. The lack of evidence for a difference in level of injecting risk-taking behaviour between pregnant IDUs enrolled in MMT and women IDUs not enrolled in treatment suggests the need for additional strategies among pregnant IDUs to reduce IDU and injecting risk-taking behaviour. Possible strategies include maintenance on higher doses of methadone and the application of relapse prevention strategies.     

Use of buprenorphine in HIV-infected injection drug users: negligible impact on virologic response to HAART. The Manif-2000 Study Group

Some HIV-infected injecting drug users (IDUs) on drug abuse maintenance treatment have access to highly active antiretroviral therapy (HAART); this raises questions about the effects of individual treatments on the efficacy of HAART. The French Cohort Study of HIV-infected IDUs - MANIF-2000 - allowed one to assess whether buprenorphine differentially impacts efficacy of HAART. Of the 103 HAART-treated patients, (excluding active IDUs and patients on methadone), 20 were on buprenorphine substitution treatment and 83 were ex-IDUs. A linear regression model used the differences in viral load titre before and after treatment initiation, as a dependent variable, and showed that buprenorphine treatment was not significantly associated with viral load trend. This was also the case when adjusting for other potential confounders, and suggests that there is no major short-term influence of buprenorphine on HIV viral load in HAART-treated patients.     

德国的阿片类依赖替代治疗(英文)

经过漫长而激烈的争论,德国于1987年首次引进了美沙酮维持治疗。最初,由于入治标准严格,接受治疗的人数很少,但自1990年后接受治疗的人数迅速上升,到2005年底已有61 000人。在德国每位全科医生只要完成了成瘾医学的培训都允许为阿片类成瘾病人开具替代治疗药物。目前德国有2700个全科医生在为阿片类药物成瘾病人开具处方。每位参加维持治疗的病人需接受社会心理治疗。研究结果和实践经验表明,病人从美沙酮维持治疗中获得了实质性的好处,他们的身心健康得到了改善。美沙酮维持治疗的留治率高(65% -85%),对HIV和肝炎的评估和坚持治疗十分重要;在促进病人回归社会方面也是极其重要的因素;在降低药物相关伤害方面如:减少共患疾病、死亡和预防感染性疾病具有重要的作用。有10%的人在长期的治疗过程中戒掉了毒品。虽然丁丙诺啡正在显示其重要性,但是美沙酮仍是主要的替代药物。在农村,参加美沙酮维持治疗仍是难题。虽然一致认为工作是治疗的正性因素,但对病人来说就业机会很少。德国监狱的替代治疗采用不同的准入和治疗模式。准入治疗不协调,参加治疗的人数很少。无论如何,在德国替代治疗在为药物使用者提供的卫生医疗系统中发挥了重要作用。     

Drug abuse treatment as an HIV prevention strategy: a review

We review drug abuse treatment as a means of preventing infection with HIV. Thirty-three studies, with an aggregate of over seventeen thousand subjects, were published in peer-reviewed journals from 1988-1998. Research on the utility of drug abuse treatment as an HIV prevention strategy has focused primarily on methadone maintenance treatment (MMT) rather than other modalities such as residential or outpatient drug-free treatment. Recent research provides clear evidence that MMT reduces HIV risk behaviors, particularly needle-use, and strong evidence that MMT prevents HIV infection. There is less definitive evidence that MMT reduces needle-sharing and unsafe sexual behavior, or that other treatment modalities prevent HIV infection. Future research should take into account patient self-selection processes and investigate other treatment modalities for heroin and stimulant abuse to determine their effects on HIV risk behaviors and HIV infection.     

Methadone and buprenorphine-naloxone are effective in reducing illicit buprenorphine and other opioid use,and reducing HIV risk behavior—Outcomes of a randomized trial

Aims

Determine the extent to which buprenorphine injectors continue treatment with buprenorphine-naloxone or methadone, and the impact of these treatments on substance use and HIV risk in the Republic of Georgia.

Methods

Randomized controlled 12-week trial of daily-observed methadone or buprenorphine-naloxone followed by a dose taper, referral to ongoing treatment, and follow-up at week 20 at the Uranti Clinic in Tbilisi, Republic of Georgia. Eighty consenting treatment-seeking individuals (40/group) aged 25 and above who met ICD-10 criteria for opioid dependence with physiologic features and reported injecting buprenorphine 10 or more times in the past 30 days. Opioid use according to urine tests and self-reports, treatment retention, and HIV risk behavior as determined by the Risk Assessment Battery.

Results

Mean age of participants was 33.7 (SD5.7), 4 were female, mean history of opioid injection use was 5.8 years (SD4.6), none were HIV+ at intake or at the 12-week assessment and 73.4% were HCV+. Sixty-eight participants (85%) completed the 12-week medication phase (33 from methadone and 35 from buprenorphine/naloxone group); 37 (46%) were in treatment at the 20-week follow-up (21 from methadone and 16 from the buprenorphine/naloxone group). In both study arms, treatment resulted in a marked reduction in unprescribed buprenorphine, other opioid use, and HIV injecting risk behavior with no clinically significant differences between the two treatment arms.

Conclusions

Daily observed methadone or buprenorphine-naloxone are effective treatments for non-medical buprenorphine and other opioid use in the Republic of Georgia and likely to be useful for preventing HIV infection.     

四川省凉山地区静脉吸毒人群药物滥用及其行为特征调查

目的:了解四川省凉山地区静脉吸毒人群药物滥用及行为特征情况,为采取有针对性的戒毒干预措施预防艾滋病病毒的传播提供数据.方法:以社区为基础招募了379名静脉吸毒人员,调查其人口学特征,艾滋病病毒感染情况,药物滥用的种类、吸毒方式和频率,口吸和静脉吸毒时间,共用注射器具情况等.结果:静脉吸毒人群艾滋病病毒感染率为11.3%(43/379).379名被调查者全部为海洛因滥用者,其中247人(65.2%)单独使用过海洛因,297人(78.4%)混合注射过海洛因与安定,滥用过的其他药物有安定(8.2%)和鸦片(1.3%).300人(79.2%)每天静脉注射吸毒一次及以上;曾经共用注射器具静脉吸毒的为247人(65.2%),87人(35.2%)首次静脉注射吸毒即与他人共用注射器具;初次口吸吸毒和静脉注射吸毒的平均年龄分别为22.37岁和25.35岁,口吸吸毒和静脉注射吸毒的平均时间分别为6.41年和3.42年.结论:加强青少年、吸毒人员关于毒品危害和拒绝毒品的健康教育活动,以及开展美沙酮或丁丙诺啡口服治疗海洛因依赖者,降低静脉注射吸毒行为,控制艾滋病病毒的传播.     

Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users

This paper focuses on the evidence for the effectiveness of community-based outreach intervention as one component of a comprehensive HIV prevention model for preventing HIV infection in injecting drug user (IDU) populations. Three empirical questions guided the review of the evidence. This article includes primarily published literature on community-based outreach derived mostly from developing countries but also unpublished literature. Wherever possible, evidence from multi-country, multi-site studies or meta-analytical studies is included. More than 40 published studies reveal that injecting drug users (IDUs), who are reached by community-based outreach and provided with access to risk reduction services, report reducing HIV risk behaviours. The strength of the evidence was assessed using Hill's criteria, which permit a review of multiple studies with different designs. Using the criteria, it is possible to infer causation about the evidence of effectiveness of the intervention. The evidence for the effectiveness of a community-based outreach strategy is strong. Despite evidence from 20 years of evaluation studies of the effectiveness of community-based outreach, a huge gap exists in most countries between the number of IDUs who want or could benefit from outreach services and the number of IDUs who actually receive them. Findings from evaluation studies on the effectiveness of community-based outreach must be made accessible, disseminated globally and provided to policy- and decision-makers to persuade them to take action and implement scaled-up prevention programmes. This requires ongoing advocacy and constant strengthening of the evidence base. Plans are needed to link evidence-based findings with technical assistance as well as training to enhance the capacity of regions and countries to introduce, scale up and sustain HIV prevention outreach to IDUs as part of a comprehensive HIV prevention strategy.     

An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research

AIM: To summarize the major findings of the five Cochrane reviews on substitution maintenance treatments for opioid dependence. METHODS: We conducted a narrative and quantitative summary of systematic review findings. There were 52 studies included in the original reviews (12,075 participants, range 577-5894): methadone maintenance treatment (MMT) was compared with methadone detoxification treatment (MDT), no treatment, different dosages of MMT, buprenorphine maintenance treatment (BMT), heroin maintenance treatment (HMT), and l-alpha-acetylmethadol (LAAM) maintenance treatment (LMT). MEASUREMENTS: Outcomes considered were retention in treatment, use of heroin and other drugs during treatment, mortality, criminal activity, and quality of life. FINDINGS: Retention in treatment: MMT is more effective than MDT, no treatment, BMT, LMT, and heroin plus methadone. MMT proved to be less effective than injected heroin alone. High doses of methadone are more effective than medium and low doses. Use of heroin: MMT is more effective than waiting list, less effective than LAAM, and not different from injected heroin. No significant results were available for mortality and criminal activity. CONCLUSIONS: These findings confirm that MMT at appropriate doses is the most effective in retaining patients in treatment and suppressing heroin use but show weak evidence of effectiveness toward other relevant outcomes. Future clinical trials should collect data on a broad range of health outcomes and recruit participants from heterogeneous practice settings and social contexts to increase generalizability of results.     

Injecting drug users, HIV risk behaviour and shooting galleries in Rajshahi, Bangladesh

The purpose of this study was to investigate HIV risk behaviours of IDUs and the drug scene in Bangladesh. The setting for the study was the city of Rajshahi, in the northwestern area of Bangladesh, which shares a border with India. Sixty-four clients of a drug treatment agency were surveyed about their drug use, drug injecting, sexual behaviour and knowledge about HIV and AIDS. All participants were males with a mean age of 32 years. Most participants had no or little formal education. All participants had injected drugs, primarily buprenorphine. The majority of participants were long-term drug users who had begun injecting drugs recently - 70% had commenced injecting in the last 3 years. Sexual contact with sex workers (50%) and with casual partners (85%) was common among participants. Although most participants had heard of AIDS, few knew how HIV is transmitted. Most participants (81%)injected in groups at shooting galleries where they paid another to inject them. The shooting galleries operated without concern for hygiene or user safety. The potential for HIV to spread among IDUs and onto their non-injecting sexual partners in Bangladesh is cause for concern. A rapid assessment of HIV prevalence among IDUs in Bangladesh is urgently required. [Hossain M. Injecting drug users, HIV risk behaviour and shooting galleries in Rajshahi, Bangladesh. Drug Alcohol Rev 2000;19:413-417]     

Methadone Maintenance Therapy Outcomes in Iran

Introduction: Because of the increasing number of injecting drug users (IDUs) in Iran and the risk of the spread of HIV infection, harm reduction programs have been considered for conventional law enforcement measures. The aim of this study was to evaluate the efficacy of methadone maintenance therapy (MMT) in IDUs and the associated health and social outcomes. Material and Methods: This case–control study was conducted at the Persepolis Harm Reduction Center in Tehran during the year 2006. Data were gathered from two groups of randomly chosen patients. The first group consisted of 75 IDU patients who had undergone at least 6 months of methadone treatment (the MMT group), and second group consisted of 75 newly admitted clients (the control group). Participants were assessed on their dangerous injection and sexual behaviors, social well-being, and patterns of drug use. The results were compared between the two groups. Results: The mean age of participants in the two groups was almost the same (34.28 years in the control group and 35.68 years in the MMT group, p >.05). Prevalence of drug injection in the MMT group was less than that in the control group (16% vs. 100%). There was also a dramatic difference in needle and syringe sharing (40% in the control group vs. 4% in the MMT group) but not in crimes and arrests (p = .4). Those in the MMT group had a better relationship with their families, partners, coworkers, and neighbors compared with controls. There was no considerable difference in dangerous sexual behaviors between the two groups. Conclusions: Given the large number of HIV-positive cases among IDUs and considering that injection drug use is the main spreading factor for HIV, MMT would play a major role in controlling the HIV epidemic through reduction of heroin injection and the risk behaviors related to it. High inflation rate, lack of interorganization coordination, budget limitation, and no follow-up were the most important limitations of this study.     

Feasibility of buprenorphine and methadone maintenance programmes among users of home made opioids in Ukraine

BackgroundOpioid substitution therapy (OST) in the Ukraine was not provided until 2004. Methadone maintenance therapy only became available in May 2008. Injecting drug users in Ukraine are predominantly injecting self-made opioid solution (‘Shirka’). A feasibility study on buprenorphine and methadone maintenance treatment was conducted in 2008.MethodsA total of 331 opioid dependent patients were given buprenorphine (n = 191) or methadone (n = 140) as a substitute, and a survey of substance use, HIV transmission risks, and legal and social status was conducted at baseline and at six months follow-up.ResultsIllegal substance use, illegal activities, incomes and HIV related transmission risks were highly reduced, whereas employment rates and psychiatric problems improved. Retention was comparatively high among the patients in buprenorphine (84.8%) and in methadone maintenance treatment (85.0%) after six months of treatment.ConclusionThese data show the successful implementation of OST in the Ukraine among drug users who were predominantly injectors of self-made opioid solutions. Continuing scale-up of OST in the Ukraine is therefore both feasible and highly recommended.     

404名静脉吸毒者HIV感染状况及行为调查分析

目的：了解梧州市2008年吸毒人群HIV感染状况以及危险因素行为特征,为预防控制工作提供依据。方法：2008年4-6月对梧州市市辖区社区中的静脉吸毒人员进行行为学调查,并采血样进行HIV、梅毒抗体检测。结果：共调查了404名静脉吸毒者,吸毒以20—39岁男性为主,吸毒方式以静脉注射吸毒为主,占96．53％（390／404）;吸毒人群HIV抗体阳性率为39．11％（158／404）,梅毒抗体阳性率为1．24％（5／404）。结论：梧州市静脉吸毒人群中不仅存在因静脉注射吸毒经血传播HIV的危险,还存在因性接触传播的危险因素。应及时开展宣传教育以及行为干预工作。     

Women and Substance Use in India and Bangladesh

Given the feminization of the HIV epidemic in India and Bangladesh, understanding substance-use-related concerns among women is important for effective HIV prevention. This review is based on published research, reports (2000–2005), and primary data from treatment centers for drug-using women. We identify four main themes: (a) opioid use and injecting drug use in women, (b) alcohol use in sex work settings, (c) sexual transmission of HIV from male-injecting drug users (IDUs) to their regular female sex partners, and (d) sexual violence among female partners of substance-using men. We urge for focused HIV prevention interventions targeting substance-using women and female sex partners of male substance users to reduce vulnerability.     

Women and substance use in India and Bangladesh

Given the feminization of the HIV epidemic in India and Bangladesh, understanding substance-use-related concerns among women is important for effective HIV prevention. This review is based on published research, reports (2000-2005), and primary data from treatment centers for drug-using women. We identify four main themes: (a) opioid use and injecting drug use in women, (b) alcohol use in sex work settings, (c) sexual transmission of HIV from male-injecting drug users (IDUs) to their regular female sex partners, and (d) sexual violence among female partners of substance-using men. We urge for focused HIV prevention interventions targeting substance-using women and female sex partners of male substance users to reduce vulnerability.     

Networks and HIV risk: an introduction to social network analysis for harm reductionists

There is considerable evidence for the belief that networks affect the probability that an injecting drug user (IDU) becomes infected with HIV; the speed with which HIV travels through communities of IDUs; and the extent to which IDUs engage in risk behaviors. This paper gives a brief overview of network concepts and methods and discusses how prevention projects and /or user groups might become involved in network research alongside academic and public health researchers.     

HIV risk behaviors during pharmacologic treatment for opioid dependence: a comparison of levomethadyl acetate [corrected] buprenorphine, and methadone

The efficacies of three opioid substitution medications for reducing HIV risk behaviors in opioid-dependent patients were assessed in a randomized double-blind clinical trial comparing levomethadyl acetate [corrected] (LAAM), buprenorphine (BUP), and methadone (METH). Individually optimized flexible dosing was used for each group, with weekly possible doses of 255-391 mg of LAAM, 56-112 mg of BUP, and 420-700 mg of METH. An interview regarding specific HIV risk behaviors, including injecting, equipment sharing, and sexual activity, yielded data for pretreatment and four in-study time points for 137 subjects. Declines in risk behaviors during treatment were evident in all groups for most measures of injecting and equipment sharing. Only the METH group showed consistent declines in measures of sexual behaviors. These results demonstrate that all three medications can be highly effective in decreasing HIV risk behaviors when the dose is optimized. Reductions in sexual behaviors for the METH group are consistent with known METH side effects.     

Access to highly active antiretroviral therapy (HAART) for injecting drug users in the WHO European Region 2002-2004

Providing equitable access to highly active antiretroviral treatment (HAART) to injecting drug users (IDUs) is both feasible and desirable. Given the evidence that IDUs can adhere to HAART as well as non-IDUs and the imperative to provide universal and equitable access to HIV/AIDS treatment for all who need it, here we examine whether IDUs in the 52 countries in the WHO European Region have equitable access to HAART and whether that access has changed over time between 2002 and 2004. We consider regional and country differences in IDU HAART access; examine preliminary data regarding the injecting status of those initiating HAART and the use of opioid substitution therapy among HAART patients, and discuss how HAART might be better delivered to injecting drug users. Our data adds to the evidence that IDUs in Europe have poor and inequitable access to HAART, with only a relatively small improvement in access between 2002 and 2004. Regional and country comparisons reveal that inequities in IDU access to HAART are worst in eastern European countries.     

Malaysia and harm reduction: the challenges and responses

In Malaysia the response to illicit drug use has been largely punitive with the current goal of the Malaysian government being to achieve a drug-free society by 2015. This paper outlines the results of a desk-based situation assessment conducted over a 3-week period in 2004. Additional events, examined in 2005, were also included to describe more recent policy developments and examine how these came about. Despite punitive drug policy there has been a substantial rise in the number of drug users in the country. Over two-thirds of HIV/AIDS cases are among injecting drug users (IDUs) and there has been an exponential rise in the number of cases reported. Further, data suggest high risk drug use practices are widespread. Harm reduction initiatives have only recently been introduced in Malaysia. The successful piloting of substitution therapies, in particular methadone and buprenorphine, is cause for genuine hope for the rapid development of such interventions. In 2005 the government announced it will allow methadone maintenance programmes to operate beyond the pilot phase and needle and syringe exchange programmes will be established to serve the needs of IDUs.     

Optimal provision of needle and syringe programmes for injecting drug users: A systematic review

The introduction of needle and syringe programmes (NSPs) during the 1980s is credited with averting an HIV epidemic in the United Kingdom and Australia, but hepatitis C (HCV) incidence continues to rise among injecting drug users (IDUs). NSPs incorporating additional harm reduction strategies have been highlighted as an approach that may impact on HCV incidence. This systematic review sought to determine which approaches to the organisation and delivery of NSPs are effective. Fifteen databases were searched for studies published since 1990. Two reviewers screened all titles and abstracts, and data extraction and quality assessment of individual studies were undertaken independently by one reviewer and checked for accuracy by a second. Sixteen studies met the criteria for inclusion. Based on 11 studies there was no evidence of an impact of different NSP settings or syringe dispensation policies on drug injecting behaviours, but mobile van sites and vending machines appeared to attract younger IDUs and IDUs with higher risk profiles. Two studies of interventions aimed at encouraging IDUs to enter drug treatment reported limited effects, but one study found that the combination of methadone treatment and full participation in NSPs was associated with a lower incidence of HIV and HCV. In addition, one study indicated that hospital-based programmes may improve access to health care services among IDUs. Currently, it is difficult to draw conclusions on ‘what works best’ within the range of harm reduction services available to IDUs. Further studies are required which have a stated aim of evaluating how different approaches to the organisation and delivery NSPs impact on effectiveness.