PREVENTING HIV INFECTION AMONG INJECTING DRUG USERS IN HIGH-RISK COUNTRIES

AN ASSESSMENT OF THE EVIDENCE

Committee on the Prevention of HIV Infection Among Injecting Drug Users in High-Risk Countries

Board on Global Health

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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PREVENTING HIV INFECTION AMONG INJECTING DRUG USERS IN HIGH-RISK COUNTRIES AN ASSESSMENT OF THE EVIDENCE Committee on the Prevention of HIV Infection Among Injecting Drug Users in High-Risk Countries Board on Global Health INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the Committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 39417 between the National Academy of Sciences and the Bill & Melinda Gates Foundation and by Contract No. HQ-05-413065 between the National Academy of Sciences and the Joint United Nations Programme on HIV/AIDS. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-10: 0-309-10280-4 (Book) International Standard Book Number-13: 978-0-309-10280-3 (Book) International Standard Book Number-10: 0-309-66343-1 (PDF) International Standard Book Number-13: 978-0-309-66343-4 (PDF) Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2007 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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COMMITTEE ON THE PREVENTION OF HIV INFECTION AMONG INJECTING DRUG USERS IN HIGH-RISK COUNTRIES HUGH TILSON (Chair), University of North Carolina School of Public Health, Chapel Hill, NC APINUN ARAMRATTANA, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand SAMUEL A. BOZZETTE, The RAND Corporation, Santa Monica, and the University of California San Diego School of Medicine, La Jolla, CA DAVID D. CELENTANO, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD MATHEA FALCO, Drug Strategies, Washington, DC THEODORE M. HAMMETT, Abt Associates Inc., Cambridge, MA ANDREI P. KOZLOV, Biomedical Center and St. Petersburg University, St. Petersburg, Russia SHENGHAN LAI, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD AJAY MAHAL, Department of Population and International Health, Harvard University School of Public Health, Boston, MA RICHARD S. SCHOTTENFELD, Yale University School of Medicine, New Haven, CT SUNITI SOLOMON, Centre for AIDS Research and Education, Y.R. Gaitonde Medical Educational and Research Foundation, Chennai, India Staff ALICIA R. GABLE, Study Director ALYSON SCHWABER, Senior Program Associate SHEYI LAWOYIN, Senior Program Assistant PATRICK KELLEY, Board Director Consultants SANDRA HACKMAN, Editor LESLIE PRAY, Writer

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s (NRC’s) Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible, and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Richard Ashcroft, Queen Mary, University of London, Barts and the London Medical and Dental School, Institute of Health Sciences Education, United Kingdom Constance A. Benson, AIDS Clinical Trials Group and Antiviral Research Center, University of California San Diego Chris Beyrer, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD Robert E. Booth, University of Colorado School of Medicine, Denver, CO Lawrence O. Gostin, Georgetown University Law Center, Washington, DC, and Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD Marc N. Gourevitch, New York University School of Medicine

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Martin Iguchi, RAND Drug Policy Research Center, Santa Monica, California and University of California Los Angeles School of Public Health Adeeba Kamarulzaman, University of Malaya Medical Center, Kuala Lumpur, Malaysia Kenneth Mayer, Brown University Medical School and the Miriam Hospital, Providence, RI A. Thomas McLellan, Treatment Research Institute, Philadelphia, PA Harold Pollack, University of Chicago School of Social Service Administration Vu Minh Quan, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand and Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD David Vlahov, New York Academy of Medicine Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Arthur L. Reingold, Professor and Head, Division of Epidemiology, University of California, Berkeley; and Floyd Bloom, Chairman and Professor, Department of Neuropharmacology, The Scripps Research Institute, La Jolla, CA. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures, and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring Committee and the institution.

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Acknowledgments The Committee recognizes the tremendous efforts of several individuals whose contributions invigorated discussions at its meetings and enhanced the quality of this report. The Committee extends its most sincere gratitude to all those mentioned below. The Committee thanks the sponsors of this study, Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Bill and Melinda Gates Foundation. Special recognition goes to Anindya Chatterjee, Arminda Dayupay, Marie-Therese Drahamcha, David Haroz, Michael Iskowitz, Mahesh Malingham, Purnima Mane, Peter Piot, and Barbara de Zalduondo, at UNAIDS and David Allen and Todd Summers at the Gates Foundation for their extra effort and repeated attention in providing information and support for the study. The Committee appreciates the testimony of the following individuals at its December 2005 meeting: Andrew Ball, Chris Beyrer, Saulius Caplinskas, Monica Ciupagea, Roel Coutinho, Don Des Jarlais, Ksenia Eroshina, Michael Farrell, Loon Gangte, Peter Ghys, Tomas Hallberg, Catherine Hankins, Lily Hyde, Adeeba Kamarulzaman, Kerstin Kall, Christian Kroll, Alexey Mazus, Samuel Nugraha, Peter Piot, Gerry Stimson, Raminta Stuikyte, Oleg Tchestnov, Inga Upmace, Nikolay Volodin, Alex Wodak, George Zazulin, and Fugie Zhang. The agenda for the information-gathering workshop in which these individuals participated appears in Appendix A. The Committee would also like to express its gratitude to those who shared their extensive knowledge on this topic: Chris Buchner, Don Des

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Jarlais, Ross Gibson, Herman Joseph, Richard Needle, Pascale LeClerc, Carole Morissette, and Daniel Wolfe. The Committee would be remiss if it did not also acknowledge the hard work and dedication of the study staff from the Board on Global Health. We would like to thank Alicia Gable, study director, for her commitment to ensuring that the report would be of the highest-possible quality. To Alyson Schwaber, senior program associate, the Committee extends its gratitude for her outstanding ability to understand and analyze the research. Sheyi Lawoyin, senior project assistant, did a great job coordinating the logistics of the study. Patrick Kelley, the director of the board, was an extremely valuable resource. In addition, the Committee thanks IOM staff members Matt Solyst and Chelsie Benca for their assistance in preparing the report. Special appreciation goes to writer Leslie Pray and editor Sandra Hackman for their instrumental services. The Committee sincerely thanks research librarians Bill McLeod (IOM) and Roberta Shanman (the RAND Corporation) for assisting the Committee with literature searches. The Committee would also like to thank several consultants who assisted the Committee during the literature review: Sarah Lewis, Katherine McLean, Adriana Van Breda, and Maya Yiadom.

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Contents     Acronyms and Abbreviations   xv     Summary   1     Introduction   27 1   HIV/AIDS in Injecting Drug Users   33 2   Treatment for Drug Dependence   74 3   Sterile Needle and Syringe Access, and Outreach and Education   137 4   Taking Action   187     Appendixes     A   Agenda for Information-Gathering Meeting, Geneva, December 2005   199 B   Literature Search Strategies   205 C   Country Case Studies   211

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D   Tables Summarizing the Evidence on Multi-Component HIV Prevention Programs That Include Needle and Syringe Exchange   225 E   Additional Thoughts on a Community Randomized Trial of Multi-Component HIV Prevention Programs   269 F   Biographies   274

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TABLES, FIGURES, AND BOXES Tables 1-1   Percent of Injecting Drug Users Covered by HIV Prevention Services in 2003, by Region,   60 3-1   Studies with Drug-Related Risk Outcomes,   143 3-2   Studies with Sex-Related Risk Outcomes,   145 3-3   Studies with HIV Incidence or Prevalence Outcomes,   146 D-1   Multi-Component HIV Prevention Programs That Include Needle and Syringe Exchange (NSE) Case-Control Studies,   226 D-2   Multi-Component HIV Prevention Programs That Include NSE Prospective Cohort Studies,   230 D-3   Multi-Component HIV Prevention Programs That Include NSE Ecological Studies,   252 D-4   Multi-Component HIV Prevention Programs That Include NSE Selected Serial Cross-Sectional Studies,   258 D-5   Multi-Component HIV Prevention Programs That Include NSE Selected Cross-Sectional Studies,   262 Figure 1-1   Estimates of IDU Populations by Region,   35 Boxes S-1   Key HIV Prevention Interventions for IDUs,   4 S-2   Recommendations,   18 1-1   Amphetamine-Type Stimulants,   38 1-2   Viral Hepatitis,   40 1-3   Hierarchy of Steps IDUs Can Take to Reduce HIV Risk,   50 2-1   Definitions of Common Research Study Designs,   78 2-2   Psychosocial Interventions for Drug Dependence Treatment,   110 3-1   Potential Outcomes from Needle and Syringe Exchange,   140 3-2   Instructions for Disinfecting Syringes,   164 3-3   An Example of Outreach in India,   170 3-4   Community Randomized Trials,   174

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Acronyms and Abbreviations AIDS Acquired Immune Deficiency Syndrome AOR Adjusted Odds Ratio ART Antiretroviral Treatment ASPD Anti-Social Personality Disorder ATS Amphetamine Type Stimulants CBT Cognitive Behavioral Therapy CI Confidence Interval CM Contingency Management CRA Community Reinforcement Approach DAART Directly Administered Antiretroviral Therapy DATOS Drug Abuse Treatment Outcome Studies ESAP Expanded Syringe Access Program HBV Hepatitis B Virus HCV Hepatitis C Virus HIV Human Immunodeficiency Virus IDU(s) Injecting Drug User(s) IOM Institute of Medicine LAAM Levo-Alpha-Acetyl-Methadol

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MMT Methadone Maintenance Treatment MSIC Medically Supervised Injecting Center NA Narcotics Anonymous NADR National AIDS Demonstration Research Program NIDA National Institute on Drug Abuse (U.S.) NIMH National Institute of Mental Health (U.S.) NSE Needle and Syringe Exchange OR Odds Ratio RCT Randomized Control Trial RR Relative Risk SIF Supervised Injecting Facility STI Sexually Transmitted Infection TC Therapeutic Communities TSF Twelve-Step Facilitation UNAIDS Joint United Nations Programme on HIV/AIDS UNODC United Nations Office on Drugs and Crime VCT Voluntary Counseling and Testing WHO World Health Organization