Summary

Drug dependence is a complex, chronic, relapsing condition that is often accompanied by severe health, psychological, economic, legal, and social consequences (IOM, 1990, 1995). It is manifested by a complex set of behaviors including compulsive drug craving, seeking, and use that interferes with an individual’s physical, mental, and social functioning (IOM, 1997; McLellan et al., 2000). Similar to other chronic conditions, such as heart disease or diabetes, individuals with drug dependence can stabilize their condition by making behavioral changes and with the use of appropriate medications (WHO et al., 2004). Drug-dependent individuals have high rates of medical and psychiatric comorbidity and increased risk of premature mortality (DHHS, 2006). Injecting drug users are particularly vulnerable to HIV and other bloodborne infections (such as hepatitis C) as a result of sharing contaminated injecting equipment. All drug-dependent individuals, including injecting drug users (IDUs), may be at increased risk of HIV infection because of high-risk sexual behaviors.

There are an estimated 13.2 million injecting drug users worldwide—78 percent of whom live in developing or transitional countries (Aceijas et al., 2004). The sharing of contaminated injecting equipment has become a major driving force of the global AIDS epidemic and is the primary mode of HIV transmission in many countries throughout Eastern Europe, the Commonwealth of Independent States,1 and significant parts of Asia (UNAIDS,

1

 The Commonwealth of Independent States includes Azerbaijan, Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Turkmenistan, Uzbekistan, and Ukraine.



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 1
Summary Drug dependence is a complex, chronic, relapsing condition that is often accompanied by severe health, psychological, economic, legal, and social consequences (IOM, 1990, 1995). It is manifested by a complex set of behaviors including compulsive drug craving, seeking, and use that interferes with an individual’s physical, mental, and social functioning (IOM, 1997; McLellan et al., 2000). Similar to other chronic conditions, such as heart disease or diabetes, individuals with drug dependence can stabilize their condition by making behavioral changes and with the use of appropriate medications (WHO et al., 2004). Drug-dependent individuals have high rates of medical and psychiatric comorbidity and increased risk of premature mortality (DHHS, 2006). Injecting drug users are particularly vulnerable to HIV and other bloodborne infections (such as hepatitis C) as a result of sharing contaminated injecting equipment. All drug-dependent individuals, including injecting drug users (IDUs), may be at increased risk of HIV infection because of high-risk sexual behaviors. There are an estimated 13.2 million injecting drug users worldwide—78 percent of whom live in developing or transitional countries (Aceijas et al., 2004). The sharing of contaminated injecting equipment has become a major driving force of the global AIDS epidemic and is the primary mode of HIV transmission in many countries throughout Eastern Europe, the Commonwealth of Independent States,1 and significant parts of Asia (UNAIDS, 1  The Commonwealth of Independent States includes Azerbaijan, Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Turkmenistan, Uzbekistan, and Ukraine.

OCR for page 1
2006). In some cases, epidemics initially fueled by the sharing of contaminated injecting equipment are spreading through sexual transmission from IDUs to non-injecting populations, and through perinatal transmission to newborns. Reversing the rise of HIV infections among IDUs has thus become an urgent global public health challenge—one that remains largely unmet. STUDY GOALS AND APPROACH In response to this challenge, in 2005 the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Bill & Melinda Gates Foundation commissioned the Institute of Medicine to undertake an expedited review of the scientific evidence on strategies to prevent HIV transmission through contaminated injecting equipment, with a specific focus on high-risk2 countries—namely in Eastern Europe, the Commonwealth of Independent States, and significant parts of Asia—where injecting drug use is, or is on the verge of becoming, the primary driver of the HIV epidemic. The charge to the Committee included five questions. They are listed here in the order in which they are addressed in the chapters. The Committee found it most helpful to first discuss the evidence on the intermediate outcomes of drug-related risk (question one) and sex-related risk (question two) prior to examining the impact on HIV transmission (question three). What impact do needle and syringe exchange, disinfection programs, drug substitution programs, drug treatment programs, and counseling and education have on the extent and frequency of drug injection? What evidence is there on the extent to which these prevention strategies help reduce HIV transmission from IDUs to their sex partners and through maternal-to-child transmission to their offspring? How effective are such programs in reducing HIV transmission among IDUs? To what extent do such programs also increase the use of health and social services and drug treatment? What evidence is there that programs aimed at reducing the risk of HIV transmission among IDUs are more effective when they are part of a comprehensive array of services, which include outreach, HIV prevention education, counseling, referral to drug substitution treatment, drug rehabilitation services, and medical and psychosocial support? 2  In this report, such countries are labeled as “high-risk,” indicating that injecting drug use is, or is on the verge of becoming, the primary driver of the HIV epidemic.

OCR for page 1
In response to this charge, the Committee convened a public workshop in Geneva, Switzerland, in December 2005 to gather information from experts on IDU-driven HIV epidemics in the world’s most affected regions (see Appendix A for the meeting agenda). The Committee also conducted a comprehensive search of the English language peer-reviewed scientific literature, and evaluated previous systematic reviews and reports prepared by international organizations (see Appendix B for further detail on the Committee’s review methods). To assess this evidence, the Committee held a closed meeting in Washington, DC, in March 2006, and also conducted numerous conference calls. Although the report focuses on HIV prevention for IDUs in high-risk countries, the Committee considered evidence from countries around the world. The findings and recommendations of this report are also applicable to countries where injecting drug use is not the primary driver, but in which injection drug use is nevertheless associated with significant HIV transmission. HIV PREVENTION STRATEGIES FOR IDUS This report focuses on programs designed to prevent the transmission of HIV among IDUs. These programs range from efforts to curtail non-medical drug use to those that encourage reduction in high-risk behavior among drug users. The term “harm reduction” is often used to describe programs such as sterile needle and syringe access, because their primary aim is to reduce the harms related to drug use among those who are unable or unwilling to stop using drugs. However, because the term has a wide range of interpretations, the Committee refers to all interventions in this report as HIV prevention programs for IDUs. The Committee grouped the wide range of HIV prevention strategies for IDUs into three categories: (1) drug dependence treatment, which include both pharmacotherapies and psychosocial interventions; (2) sterile needle and syringe access; and (3) outreach and education programs (see Box S-1). Other HIV prevention strategies, such as voluntary counseling and testing, antiretroviral therapy, and prevention and treatment of sexually transmitted infections, are important for IDUs but also apply to broader populations. While there is a large body of evidence evaluating the effectiveness of these interventions, the Committee’s review was limited to those prevention interventions specific to IDUs. Therefore, Chapter 1 includes only a brief overview of these broader interventions. The most effective way to reduce the risks of HIV transmission among injecting drug users is to stop drug use. However, not all drug users are ready or able to take this step. An individual IDU’s risk of HIV infection is mediated by both individual-level factors (such as severity of dependence

OCR for page 1
BOX S-1 Key HIV Prevention Interventions for IDUs Drug treatment—pharmacotherapies Two primary types of pharmacotherapies are available for treating opioid dependence: agonist agents and antagonist agents. No pharmacotherapies have been found to be consistently efficacious in treating stimulant dependence. Opioid agonist maintenance medications work by preventing withdrawal symptoms and reducing opioid cravings—and therefore the need to use illicit drugs—and also by diminishing the effects of opioid use by creating cross-tolerance to their effects (IOM, 1995). Agonist medications have two primary clinical applications: they can be used on a limited basis to facilitate opioid detoxification,a or they can be administered over a longer period as a maintenance treatment (IOM, 1995). This report focuses on the latter application. In maintenance therapy, the agonist agent is administered at higher doses for a sustained period. The goal of maintenance treatment is to reduce illicit drug use and high-risk behavior by building cross-tolerance to the effects of other opioids, thereby allowing patients to stabilize physiologically and psychologically, so they can reengage in normal life activities (IOM, 1990; WHO et al., 2004). Due to their long half life and resulting steady state, opioid agonists are not intoxicating and do not impair function when used at clinically appropriate and stable doses over time (IOM, 1990, 1995). Methadone, a full opioid agonist, is the most widely used and researched agonist maintenance medication for the treatment of opioid dependence (WHO et al., 2004). Buprenorphine is a partial opioid agonist that is used increasingly as an alternative to methadone. Both methadone and buprenorphine are classified as psychotherapeutic medicines for substance dependence treatment programs on the World Health Organization (WHO) list of essential medicines (WHO, 2005c). Other pharmacological agonist agents have been studied in limited settings, but are not widely used and are not reviewed in this report (MacCoun and Reuter, 2001; WHO et al., 2004). An alternative to opioid agonists are antagonist agents that block the effects of opioids. Naltrexone, the most widely used opioid antagonist, helps patients maintain long-term abstinence from opioids (WHO, 2005a). Oral naltrexone provides a relatively long-lasting blockade (1 to 3 days, depending on the dose) of euphoric or rewarding effects of heroin or other opioids, and thus may help prevent resumption of opioid use (O’Brien and Kampman, 2004). New long-acting, injectable formulations of naltrexone produce adequate opioid blockade for up to 1 month (Dunbar et al., 2006). Before beginning naltrexone treatment, patients must be detoxified (medically withdrawn from heroin or other opioids), because naltrexone will precipitate severe withdrawal symptoms in people physically dependent on opioids (O’Brien and Kampman, 2004).

OCR for page 1
Drug treatment—psychosocial A second major approach to drug treatment involves psychosocial interventions, which include a broad range of psychological and behavioral strategies, used either alone or in combination with pharmacotherapies and other medical or social interventions (Mayet et al., 2004). These interventions may be provided with varying levels of intensity, frequency, and duration, using different approaches including outpatient, partial hospital, hospital, or residential-based programs. Psychosocial interventions may be delivered in individual or group settings, and may also include family members in order to address family functioning (e.g., through behavioral family therapy). Examples of psychosocial interventions include specific behavioral interventions (e.g., cognitive behavioral therapy, contingency management) as well as collection of program models (e.g., therapeutic communities, 12-step programs) (see Chapter 2, Box 2.2 for a description of these interventions). Sterile needle and syringe access Sterile needle and syringe access may include needle and syringe exchange; the legal, accessible, and economical sale of needles and syringes through pharmacies, voucher schemes, physician prescription programs, or vending machines; supervised injecting facilities or rooms; and disinfection programs. In most cases, needle and syringe exchange (NSE) is part of a multi-component HIV prevention effort. The Committee uses the term “multi-component HIV prevention programs that include needle and syringe exchange” to refer to programs that combine NSE with one or more of the following services: outreach, health education in risk reduction, condom distribution, bleach distribution coupled with education on needle disinfection, and referrals to substance abuse treatment and other health and social services. Outreach and education Outreach and education rely on peers and local health workers to identify IDUs and provide education on preventing HIV infection, and to serve as guides to health and social services (WHO, 2004a). Outreach workers may distribute information on HIV/AIDS, bleach kits for disinfecting injection equipment, and condoms. While some programs are linked to needle and syringe exchanges or drug treatment clinics, outreach efforts often occur outside clinical settings and separate from other interventions.    aDetoxification refers to medically supervised withdrawal to a drug-free state over a short period of time (typically 5–7 days, but up to several months). When used to assist with detoxification, the agonist agent helps to relieve patient discomfort during withdrawal and the dosage is slowly tapered over time until the person reaches a drug-free state (IOM, 1990; 1995). Detoxification alone is not considered an effective treatment (IOM, 1990). Studies show users have high rates of relapse to drug use when detoxification is not followed by further therapeutic intervention (IOM, 1990).

OCR for page 1
and co-existing psychiatric disorders) and structural-level, or environmental, factors (such as drug laws and law enforcement and socioeconomic stability) (Rhodes et al., 2005). The vast majority of HIV prevention efforts target the risk behavior of individual drug users (Rhodes et al., 2005), for example, through drug treatment or outreach. Structural-level interventions, which attempt to create an environment supportive of individual behavioral change, have received less attention from researchers and policymakers (Rhodes et al., 2005; Burris et al., 2004). Examples of structural-level interventions include legal reform and programs to reduce stigma and discrimination against HIV-infected people and drug users. CONCLUSIONS ON THE EFFECTIVENESS OF HIV PREVENTION INTERVENTIONS The Committee’s major conclusions and key recommendations regarding the five questions in the charge follow (see Box S-2 for a complete list of recommendations): Question 1: What impact do intervention programs have on the extent and frequency of drug injection? The Committee interpreted this question as asking about the extent to which these interventions affect drug-related HIV risk behavior, including frequency of drug use, injection, and sharing of contaminated equipment. Drug Treatment Pharmacotherapies: Strong and consistent evidence from a number of well-designed, randomized controlled trials shows that opioid agonist maintenance treatment—including methadone and buprenorphine—is effective in reducing illicit opioid use and increasing retention of opioid-dependent patients in drug abuse treatment (Mattick et al., 2003a,b; Gowing et al., 2004, 2005). There is also strong evidence that this treatment reduces drug-related HIV risk behavior, including frequency of injecting and sharing of equipment (Gowing et al., 2004, 2005). Given the strong evidence of its effectiveness, opioid agonist maintenance treatment should be made widely available, where feasible. The medication should be provided in sufficiently high doses and for a sufficient duration for therapeutic effects to occur (Sees et al., 2000; Vanichseni et al., 1991; Strain et al., 1993; Faggiano et al., 2003). Programs should be scaled up enough to exert a public health impact, provide adequate public health infrastructure, include a plan for sustainability, and balance strategies to decrease potential diversion of treatment drugs with strategies to disseminate them.

OCR for page 1
Despite strong pharmacological evidence and theoretical potential for naltrexone—an opioid antagonist (see Box S-1)—evidence regarding its efficacy in controlled clinical trials is inconclusive. Efficacy and effectiveness studies of naltrexone treatment have been limited by problems with high patient attrition and the limited patient appeal of naltrexone (Johansson et al., 2006; Minozzi et al., 2006). However, naltrexone may be effective when used in circumstances where patients’ adherence to medication and retention in treatment can be closely monitored and facilitated (Cornish et al., 1997; Tennant et al., 1984; Washton et al., 1984; Krupitsky et al., 2004, 2006). Given its potential benefits and lack of harmful effects, naltrexone should be made available, where feasible, as part of a multi-component drug treatment strategy. However, more research is needed on the effectiveness of naltrexone for various patient populations and settings. No pharmacotherapies have been found to be consistently efficacious in treating stimulant dependence. More research is urgently needed to identify effective pharmacotherapies for stimulant dependence, particularly for amphetamine-type stimulants, which have emerged as a major problem in many parts of the world. Psychosocial: While opioid agonist maintenance therapy has been shown to be very effective in treating opioid dependence, no psychosocial intervention alone—without additional pharmacotherapy—has been shown to be efficacious in treating opioid dependence. Research shows that adjunctive psychosocial interventions may improve outcomes for individuals enrolled in opioid agonist treatment (McLellan et al., 1993), but more research is needed on the benefit and cost-effectiveness of adding psychosocial interventions to such treatment in high-risk countries, and the effectiveness of those interventions in particular cultural contexts and patient subgroups. More research is also needed to determine the relative effectiveness of various psychosocial interventions in treating opioid dependence in places where opioid agonist maintenance therapy is not available or accessible. Because proven pharmacological interventions are available only for opioid addiction and not for stimulants or other classes of injectable drugs, psychosocial approaches are the primary treatment option for individuals dependent on these substances. One such approach—contingency management—entails consistently rewarding patients (with monetary vouchers or other reinforcers) who remain abstinent or fulfill other verifiable treatment objectives, and withholding rewards when patients do not abstain (or successfully accomplish other specified objectives). A number of randomized controlled trials have found that contingency management is associated with longer retention in treatment, and time abstinent from stimulants, among individuals who are primarily dependent on stimulants (Higgins et al., 1991, 1993, 1994, 2000; Petry et al., 2004), and among

OCR for page 1
individuals who are dependent on both stimulants and opioids and enrolled in agonist maintenance therapy (Piotrowski et al., 1999; Schottenfeld et al., 2005; Peirce et al., 2006). While most studies have examined the efficacy of contingency management for cocaine users, two randomized clinical trials show that it is efficacious in reducing methamphetamine use (Shoptaw et al., 2005, 2006). More research is needed to develop cost-effective and feasible alternatives to voucher-based contingency management for treating stimulant dependence that can be implemented outside research settings. There is also modest evidence of effectiveness for several additional psychotherapeutic approaches to treating stimulant abuse. These include combined individual drug counseling and intensive group drug counseling, cognitive behavioral therapy, and the community reinforcement approach combined with contingency management (Crits-Christoph et al., 1999; Maude-Griffin et al., 1998; Monti et al., 1997; McKay et al., 1997; Carroll et al., 1994; Higgins et al. 2003; Roozen et al., 2004) (see Chapter 2, Box 2.2 for definitions of these interventions). There is relatively weak evidence regarding the effectiveness of therapeutic communities, chemical dependency programs, and drug anonymous treatments, but these are an important treatment options for opioid-dependent individuals who will not accept or cannot access opioid agonist maintenance treatment, or for individuals dependent on other classes of drugs (IOM, 1990; Hubbard et al., 2003). Studies have found that length of time in treatment in these programs is the strongest predictor of positive treatment outcomes. Given the potential benefits and lack of harmful effects, the following treatments should also be made available as part of a multi-component treatment system, where feasible, but should be accompanied by rigorous evaluation: (1) specific behavioral interventions (contingency management, cognitive behavioral therapy, community reinforcement approach, and individual drug counseling for treating stimulant dependence); and (2) chemical dependency treatment, therapeutic communities, and Drug Anonymous groups for patients dependent on any drug class who are interested in abstinence-oriented treatment. Sterile Needle and Syringe Access Multi-component programs that include needle and syringe exchange: A large number of studies and review papers—most from developed countries—show that participation in multi-component HIV prevention programs that include NSE is associated with a reduction in drug-related HIV risk behavior, including self-reported sharing of needles and syringes, unsafe injection and disposal practices, and frequency of injection. Al-

OCR for page 1
though many of the studies have design limitations, this finding is consistent across a large number of studies. One concern that has been raised is whether HIV prevention programs that include needle and syringe exchange leads to unintended consequences. The few studies that have examined the unintended consequences of programs that include NSE found no evidence that they lead to more new drug users, more frequent injection among established users, expanded networks of high-risk users, changes in crime trends, or more discarded needles in the community. However, few studies have specifically focused on these outcomes, and this issue could benefit from further study. Given consistent evidence that multi-component HIV prevention programs that include sterile needle and syringe is associated with reductions in drug-related HIV risk behavior, such programs should be implemented where feasible. Alternative access to needles and syringes: Eliminating criminal penalties for possessing needles and syringes—and enhancing legal access via pharmacy sales, voucher schemes, and physician prescription programs—are alternative avenues for making sterile needles and syringes available to IDUs. Evaluations of these strategies have primarily been conducted in the United States and have focused on the acceptability of such programs by drug users, pharmacists, and physicians. A few studies have examined the impact on drug-related HIV risk behavior, and found suggestive evidence of a reduction. Evidence regarding supervised injecting facilities and vending machines—while encouraging—is insufficient for drawing conclusions on their effectiveness in reducing drug-related HIV risk among IDUs. Outreach and Education Several studies and reviews from the developed world—most with weak designs—show a degree of consistency in finding that outreach reduces self-reported drug-related risk behavior. A review by Coyle et al. (1998) included studies that consistently reported that after an outreach intervention, significant declines occurred in self-reported injection drug use (10 of 11 studies), injection frequency (17 of 18 studies), reuse of needles and syringes (16 of 20 studies), and reuse of other equipment such as cookers, cotton, and rinse water (8 of 12 studies). A later review article by Needle and colleagues (2005) updated the 1998 review and confirmed findings that outreach results in self-reported reduction in HIV-related risk behavior. Outreach services should be made available to provide education on risk reduction and links to sterile needle and syringe access programs, drug treatment, and medical and social services for hard to-reach IDUs.

OCR for page 1
Question 2: What evidence is there on the extent to which these prevention strategies help reduce HIV transmission from IDUs to their sex partners, and through maternal-to-child transmission to their offspring? Sexual Transmission Because the primary objective of drug treatment is to reduce or stop drug use, and the goal of sterile needle and syringe access is to reduce exposure to bloodborne infections through contaminated injecting equipment, one would not necessarily expect to see an effect of these interventions on sex-related HIV risk behavior, unless they are combined with additional risk reduction efforts targeting sexual behavior. And indeed, evidence of such an impact is lacking. Drug Treatment Evidence from observational studies is weak and inconclusive on whether opioid agonist therapy alone is associated with reductions in high-risk sexual behavior (Gowing et al., 2004, 2005). Some studies suggest that methadone maintenance therapy is associated with small reductions—compared with pretreatment baseline measures—in the number of sexual partners and exchanges of sex for money or drugs, but that it has virtually no effect on reported rates of unprotected sex (Gowing et al., 2004, 2005). One study assessed the impact of naltrexone on self-reported high-risk sex behavior (Krupitsky et al., 2006). While patients who remained in treatment reported declines in high-risk sex behavior, none of the changes were statistically significant. Some evidence shows that targeted psychosocial interventions are effective in reducing sex-related HIV risk behavior among stimulant-dependent individuals (Prendergast et al., 2001; Gibson et al., 1998; Shoptaw et al., 2005). Efforts should be made to combine effective programs that address sex-related HIV risk behavior with drug treatment programs. Sterile Needle and Syringe Access Programs Few studies have evaluated the effect of NSEs on sex-related HIV risk behavior. In two early prospective cohort studies, participants in needle and syringe exchange reported decreases in sex-related risk behavior (Donoghoe, 1989; Hart, 1989). However, this issue has not been well studied, and the existing evidence is insufficient to determine the effectiveness of NSE in reducing sex-related risk. Sterile needle and syringe access programs should focus additional efforts on reducing sex-related HIV risk behavior.

OCR for page 1
Outreach and Education There is limited evidence that outreach influences self-reported sex-related risk. A review by Coyle et al. (1998) found that 16 of 17 studies showed an increase in self-reported condom use, or a decrease in self-reported unprotected sex, after outreach. The review authors note, however, that a large percentage of IDUs continued to practice high-risk sexual behavior. A review by Needle et al. (2005) showed that outreach can increase condom use, but found smaller reductions in sex-related HIV risk behavior than in drug-related HIV risk behavior. A meta-analysis by Semaan et al. (2002) showed that some interventions have lowered sexual risk among IDUs, including outreach based on multiple theories and strategies, peer interventions, and skills training. A study of network-oriented peer outreach suggests that interventions that focus on social roles and identity can reduce injection risk behavior and increase condom use with casual sex partners (Latkin et al., 2003). Outreach and education programs should focus more on reduction of sex-related HIV risk behavior. Perinatal Transmission Perinatal transmission from HIV-infected female IDUs and infected female sex partners of IDUs to their children is a growing concern. The magnitude of IDU-associated perinatal transmission has not been systematically examined, but some studies suggest that it is a major problem. For example, according to one report, most HIV-infected infants born in the Russian Federation between 1996 and 2001 apparently had mothers who were either IDUs or sexual partners of IDUs (UNODC, 2005). The risk of mother-to-child transmission can be greatly reduced by providing antiretroviral drugs to women during pregnancy and labor, and to infants during the first weeks of life (WHO, 2004b). The World Health Organization provides recommendations on using antiretroviral therapy to prevent mother-to-child transmission (WHO, 2004b). Question 3: How effective are drug treatment programs, sterile needle and syringe access programs, and outreach in reducing HIV transmission among IDUs? Drug Treatment Pharmacotherapies: Evidence from prospective cohort and case-control studies shows that continuous opioid agonist maintenance treatment is associated with protection against HIV seroconversion (Moss et al., 1994;

OCR for page 1
interventions that provide access to sterile injecting equipment or opioid agonist treatment negatively because these interventions aim to reduce the harms related to drug use rather than prevent drug use itself (NRC and IOM, 1995; Gostin, 1991). These groups may see such harm reduction efforts as condoning rather than condemning illegal drug use. Local communities may also object to programs that include needle and syringe exchange and opioid agonist maintenance treatment because they fear that these programs will attract drug users who may commit crimes and discard needles and other drug paraphernalia in their neighborhoods (NRC and IOM, 1995). Several studies suggest that the involvement and education of key stakeholders, such as community members, government agencies, nongovernmental groups, public health officials, and law enforcement officials are critical to the success of HIV prevention programs for IDUs. Consultation with community leaders before the initiation of needle and syringe exchange in Thailand and Vietnam was key to their success (Gray, 1995; 1998; Quan et al., 1998). A key realization when such communication occurs is that many disagreements over priorities and strategies stem from a lack of information about the focus, methods, and evidence base of the competing factions. A common understanding that each domain wishes to prevent the needless human suffering of an emerging HIV epidemic is essential. The Committee recommends that public health and criminal justice officials, key community leaders (religious, educational), and community members work together at international, national, regional, and local levels to develop interventions that balance their respective missions in fighting both HIV/AIDS and drug epidemics. Concerted national efforts to limit the transmission of HIV among IDUs must begin now. Nations must approach these efforts with both immediacy, to break the cycle of HIV transmission, but also with a longer-term view, to sustain progress. Although reviewing the evidence on primary programs for preventing drug use was beyond the scope of its charge, the Committee believes that programs to prevent the initiation of injecting drug use—and drug use in general—can and should be part of a comprehensive, sustained approach to preventing HIV transmission among IDUs. Broader population-based efforts at HIV awareness and prevention can provide a foundation for sustaining such efforts for IDUs. Similarly, investments in the infrastructure to deliver clinical and supportive services to the general population will be needed and will have benefits beyond the IDU population. Maintaining infrastructure and sustaining funding is central to ensuring continuous services. Programs that do not have sustainable funding are at risk of interruption. Service interruptions could have serious implications for individuals receiving medication

OCR for page 1
for opioid dependence and other IDUs receiving treatment or preventive services. As part of a sustained effort, the Committee repeats its recommendation that such approaches be monitored and evaluated, and modified based on such evaluations. Scale-up of prevention efforts should include staggered program designs or other approaches that permit the evaluation of effectiveness, alongside more rigorous efforts to experiment with different implementation choices to see which ones work best. CONCLUSION Nations where the HIV pandemic is newly emerging can and should take effective action now to stem the tide of this tragic and preventable illness. In countries where injecting drug use is the primary source of HIV infection, national programs must address the challenges of both drug use and HIV. The Committee has reviewed the evidence regarding interventions for injecting drug use and HIV among IDUs, and hopes it has provided policymakers a knowledge base regarding what works. The Committee recognizes though that each country will pursue a different combination of interventions, reflecting its economic circumstances and legal, ethical, and cultural traditions. However, these policy decisions should not be based on erroneous understanding if scientific truth is available. The Committee believes that the evidence-based conclusions and recommendations in this report can provide an important foundation for governments and communities engaging in economic, legal, and ethical debates about these issues. Evidence on effective interventions provides a solid basis for action now. The experiences of other nations with extensive HIV epidemics underscore the urgent need for an immediate response. As policy unfolds into programmatic action, nations should also evaluate their implementation, to inform the next generation of responses to drug dependence and HIV.

OCR for page 1
BOX S-2 Recommendations Recommendations Regarding Treatment for Drug Dependence (Chapter 2) Recommendation 2-1: Given the strong evidence of its effectiveness in treating opioid dependence, opioid agonist maintenance treatment should be made widely available where feasible. Such programs should include: The necessary infrastructure to make treatment widely available (e.g., clinics, trained health workers) and a strategy to ensure sustainability. Assurance of adequate dosage and treatment duration. A balance between strategies to decrease diversion of treatment medication and strategies to disseminate the treatment. An evaluation component to monitor treatment implementation, quality, and outcomes. Monitoring of potential drug interactions between antiretroviral medications and opioid agonist maintenance drugs for HIV-infected IDUs. Recommendation 2-2: Given the potential benefits and lack of harmful effects, the following treatments should also be made available as part of a multi-component treatment system, where feasible, but should include a rigorous evaluation component: Naltrexone treatment for opioid-dependent patients interested in abstinence-oriented treatment. Specific behavioral treatments (contingency management, cognitive behavioral therapy, community reinforcement approach, motivational interviewing, and individual drug counseling) for treating stimulant dependence. Chemical dependency treatment, therapeutic communities, and Drug Anonymous groups for patients dependent on any drug class who are interested in abstinence-oriented treatment. Recommendation 2-3: Given the relative weakness of the evidence, further research should occur on the following issues related to treatment for drug dependence: The additional benefits and cost-effectiveness of adding psychosocial interventions to opioid agonist maintenance treatment for opioid-dependent people in high-risk countries, and the relative effectiveness of those interventions in particular cultural contexts and for particular patient subgroups. Pharmacotherapies for stimulant abuse, particularly amphetamine-type stimulants which have emerged as a major problem in many parts of the world. The effectiveness of naltrexone for different patient populations and in different settings. The relative effectiveness of various psychosocial interventions in treating opioid dependence in places where opioid agonist maintenance therapy is not available or accessible. Developing cost-effective and feasible alternatives to voucher-based contingency management approaches for treating stimulant dependence. Effective strategies for reducing sex-related risk behavior of IDUs in treatment. Optimal strategies for linking drug dependence treatment with health and social services.

OCR for page 1
Recommendations Regarding Sterile Needle and Syringe Access and Outreach and Education (Chapter 3) Recommendation 3-1: Given consistent evidence that multi-component HIV prevention programs that include sterile needle and syringe access reduce drug-related HIV risks, such programs should be implemented where feasible. Recommendation 3-2: Multi-component HIV prevention programs that include sterile needle and syringe access should: Maximize their accessibility to the largest number of IDUs by using multiple access points and methods of delivery. Focus on reducing sex-related HIV risk behavior. Actively refer IDUs to other services, such as substance abuse treatment, HIV voluntary counseling and testing and, if appropriate, antiretroviral treatment for HIV. Focus additional efforts on preventing hepatitis C infection, such as by providing sterile cotton swabs, alcohol wipes for cleaning injection sites, sterile water, cookers, and other disinfection supplies. Incorporate strong program and component evaluations, and where feasible, include comparison populations or regions. Recommendation 3-3: Because field studies have shown that drug users often fail to properly disinfect injecting equipment, concerted effort should be made to increase the uptake of effective procedures for disinfecting shared equipment. IDUs should rely on disinfection to prevent HIV and hepatitis C virus (HCV) infection only when they cannot stop injecting or do not have access to new, sterile injecting equipment. Recommendation 3-4: Outreach services should be made available to provide education on risk reduction and links to sterile needle and syringe access programs, drug treatment, and medical and social services for hard to-reach IDUs. Recommendation 3-5: The Committee recommends that additional research focus on: The impact of outreach and education and multi-component programs that include sterile needle and syringe access on sexual risk reduction. Integration of effective strategies for reducing sexual risk behavior and sexual transmission of HIV into multi-component programs that include sterile needle and syringe exchange and outreach and education. The potential unintended consequences of HIV prevention programs that include needle and syringe exchange, such as increases in new drug users or in discarded needles in the community, and strategies to address such problems, if they are found. Identifying the simplest, most acceptable effective disinfection techniques using bleach, and the best methods for educating IDUs on these techniques. The effectiveness of alternative disinfectants in field settings, particularly in countries where bleach is not available or acceptable. Identifying effective strategies for preventing HCV among IDUs. The costs and contributions of individual elements of multi-component programs that include needle and syringe exchange on HIV-related risk behavior and HIV incidence.

OCR for page 1
BOX S-2 Recommendations Recommendations Regarding Taking Action (Chapter 4) Recommendation 4-1: Because a variety of interventions have been shown to be effective, high-risk countries should act now to prevent the growing problem of HIV among IDUs, their partners, and children. Recommendation 4-2: To increase their acceptability and likelihood of success, HIV prevention interventions for IDUs should be: Tailored to local circumstances and implemented in a culturally appropriate manner; Coupled with cost-effectiveness evaluations to improve resource-allocation decisions; Scaled-up to provide adequate coverage of the interventions to the target populations in order for programs to have a public health impact; Integrated with strategies to combat stigma and discrimination among drug users and HIV- infected people; Coordinated among national, regional, and local public health, criminal justice, and community leaders to develop a framework for interventions that balance their respective missions; Complementary to broader interventions in drug use and HIV, including primary prevention; Built upon plans for fiscal and infrastructure sustainability; Coupled with monitoring and evaluation. REFERENCES Aceijas C, Stimson GV, Hickman M, Rhodes T. 2004. Global overview of injecting drug use and HIV infection among injecting drug users. AIDS. 18(17):2295–2303. Bruneau J, Lamothe F, Franco E, Lachance N, Desy M, Soto J, Vincelette J. 1997. High rates of HIV infection among injection drug users participating in needle exchange programs in Montreal: Results of a cohort study. American Journal of Epidemiology. 146(12):994– 1002. Burris S, Blankenship KM, Donoghoe M, Sherman S, Vernick JS, Case P, Lazzarini Z, Koester S. 2004. Addressing the “risk environment” for injection drug users: The mysterious case of the missing cop. Milbank Quarterly. 82(1):125–156. Cabases J, Sanchez E. 2003. Costs and effectiveness of a syringe distribution and needle exchange program for HIV prevention in a regional setting. The European Journal of Health Economics. 4(3):203–208. Carlson RG, Wang J, Siegal HA, Falck RS. 1998. A preliminary evaluation of a modified needle-cleaning intervention using bleach among injection drug users. AIDS Education and Prevention. 10(6):523–532. Carroll KM, Rounsaville BJ, Gordon LT, Nich C, Jatlow PM, Bisighini RM, Gawin FH. 1994. Psychotherapy and pharmacotherapy for ambulatory cocaine abusers. Archives of General Psychiatry. 51(12):989–997.

OCR for page 1
Cornish JW, Metzger D, Woody GE, Wilson D, McLellan AT, Vandergrift B, O’Brien CP. 1997. Naltrexone pharmacotherapy for opioid dependent federal probationers. Journal of Substance Abuse Treatment. 14(6):529–534. Coyle SL, Needle RH, Normand J. 1998. Outreach-based HIV prevention for injecting drug users: A review of published outcome data. Public Health Reports. 113(Suppl 1):19–30. Crits-Christoph P, Siquieland L, Blaine J, Frank A, Luborsky L, Onken LS, Muenz LR, Thase ME, Weiss RD, Gastfriend DR, Woody GE, Barber JP, Butler SF, Daley D, Salloum I, Biship S, Najavits LM, Lis J, Mercer D, Griffin ML, Moras K, Beck AT. 1999. Psychosocial treatments for cocaine dependence. Archives of General Psychiatry. 56:493–502. DHHS (U.S. Department of Health and Human Services). 2006. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. [Online]. Available: http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf [accessed August 3, 2006]. Donoghoe MC, Stimson GV, Dolan KA. 1989. Sexual behaviour of injecting drug users and associated risks of HIV infection for non-injecting sexual partners. AIDS Care. 1(1): 51–58. Dunbar JL, Turncliff RZ, Dong Q, Silverman BL, Ehrich EW, Lasseter KC. 2006. Single- and multiple-dose pharmacokinetics of long-acting injectable naltrexone. Alcoholism, Experimental and Clinical Research. 30(3):480–490. Faggiano F, Vigna-Taglianti F, Versino E, Lemma P. 2003. Methadone maintenance at different dosages for opioid dependence. The Cochrane Database of Systematic Reviews. (3):CD002208. Friedmann PD, Hendrickson JC, Gerstein DR, Zhang Z, Stein MD. 2006. Do mechanisms that link addiction treatment patients to primary care influence subsequent utilization of emergency and hospital care? Medical Care. 44(1):8–15. Gerstein DR, Johnson RA, Larison CL. 1997. Alcohol and Other Drug Treatment for Parents and Welfare Recipients: Outcomes, Costs, and Benefits. Washington, DC: U.S. Department of Health and Human Services. Gibson DR, McCusker J, Chesney M. 1998. Effectiveness of psychosocial interventions in preventing HIV risk behaviour in injecting drug users. AIDS. 12(8):919–929. Gleghorn AA, Doherty MC, Vlahov D, Celentano D, Jones T. 1994. Inadequate bleach contact times during syringe cleaning among injection drug users. Journal of Acquired Immune Deficiency Syndromes. 7(7):767–772. Gostin L. 1991. An alternative public health vision for a national drug strategy: “Treatment works.” Houston Law Review. 28(1):285–308. Gowing LR, Farrell M, Bornemann R, Ali R. 2004. Substitution treatment of injecting opioid users for prevention of HIV infection. The Cochrane Database of Systematic Reviews. (4):CD004145. Gowing LR, Farrell M, Bornemann R, Sullivan LE, Ali RL. 2005. Brief report: Methadone treatment of injecting opioid users for prevention of HIV infection. Journal of General Internal Medicine. 20:1–3. Gray J. 1995. Operating needle exchange programmes in the hills of Thailand. AIDS Care. 7(4):489–499. Gray J. 1998. Harm reduction in the hills of northern Thailand. Substance Use and Misuse. 33(5):1075–1091. Hagan H, Thiede H. 2000. Changes in injection risk behavior associated with participation in the Seattle needle-exchange program. Journal of Urban Health. 77(3):369–382. Hahn JA, Page-Shafer K, Lum PJ, Ochoa K, Moss AR. 2001. Hepatitis C virus infection and needle exchange use among young injection drug users in San Francisco. Hepatology. 34(1):180–187.

OCR for page 1
Hart GJ, Carvell AL, Woodward N, Johnson AM, Williams P, Parry JV. 1989. Evaluation of needle exchange in central London: Behaviour change and anti-HIV status over one year. AIDS. 3(5):261–265. Higgins ST, Budney AJ, Bickel WK, Hughes JR, Foerg F, Fenwick W. 1991. A behavioral approach to achieving initial cocaine abstinence. American Journal of Psychiatry. 148:1218–1224. Higgins ST, Budney AJ, Bickel WK, Hughes JR, Foerg F, Badger G. 1993. Achieving cocaine abstinence with a behavioral approach. American Journal of Psychiatry. 150:763–769. Higgins ST, Budney AJ, Bickel WK, Foerg FE, Donham R, Badger GJ. 1994. Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Archives of General Psychiatry. 51:568–576. Higgins ST, Wong CJ, Badger GJ, Ogden DE, Dantona RL. 2000. Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up. Journal of Consulting and Clinical Psychology. 68:64–72. Higgins ST, Sigmon SC, Wong CJ, Heil SH, Badger GJ, Donham R, Dantona RL, Anthony S. 2003. Community reinforcement therapy for cocaine dependent outpatients. Archives of General Psychiatry. 60(10):1043–1052. Hubbard RL, Craddock SG, Anderson J. 2003. Overview of 5-year follow-up outcomes in the drug abuse treatment outcome studies (DATOS). Journal of Substance Abuse Treatment. 25:125–134. IOM (Institute of Medicine). 1990. Treating Drug Problems: Volume 1. Washington, DC: National Academy Press. IOM. 1995. Federal Regulation of Methadone Treatment. Washington, DC: National Academy Press. IOM. 1997. Dispelling the Myths About Addiction. Washington, DC: National Academy Press. Iribarne C, Berthou F, Carlhant D, Dreano Y, Picart D, Lohezic F, Riche C. 1998. Inhibition of methadone and buprenorphine N-dealkylations by three HIV-1 protease inhibitors. Drug Metabolism and Disposition. 26(3):257–260. Johannson BA, Berglund M, Lindgren A. 2006. Efficacy of maintenance treatment with naltrexone for opioid dependence: A meta-analytical review. Addiction. 101:491–503. Krupitsky EM, Zvartau EE, Masalov DV, Tsoi MV, Burakov AM, Egorova VY, Didenko TY, Romanova TN, Ivanova EB, Bespalov AY, Verbitskaya EV, Naznanov NG, Grinenko AY, O’Brien CP, Woody GE. 2004. Naltrexone for heroin dependence treatment in St. Petersburg, Russia. Journal of Substance Abuse Treatment. 26(4):285–294. Krupitsky EM, Zvartau EE, Masalov DV, Tsoy MV, Burakov AM, Egorova VY, Didenko TY, Romanova TN, Ivanova EB, Bespalov AY, Verbitskaya EV, Neznanov NG, Grinenko AY, O’Brien CP, Woody GE. 2006. Naltrexone with or without fluoxetine for preventing relapse to heroin addiction in St. Petersburg, Russia. Journal of Substance Abuse Treatment. In press, corrected proof. [Available online July 24, 2006]. Latkin C, Sherman S, Knowlton A. 2003. HIV prevention among drug users: Outcome of a network-orientated peer outreach intervention. Health Psychology. 22(4):332–339. Laufer FN. 2001. Cost-effectiveness of syringe exchange as an HIV prevention strategy. Journal of Acquired Immune Deficiency Syndromes. 28(3):273–278. Lucas GM, Mullen BA, Weidle PJ, Hader S, MCaul ME, Moore RD. 2006. Directly administered antiretroviral therapy in methadone clinics is associated with improved HIV treatment outcomes, compared with outcomes among concurrent comparison groups. Clinical Infectious Diseases. 42:1628–1635. MacCoun R, Reuter P. 2001. Drug War Heresies: Learning from Other Vices, Times, and Places. Cambridge, UK: Cambridge University Press.

OCR for page 1
Mansson AS, Moestrup T, Nordenfelt E, Widell A. 2000. Continued transmission of hepatitis B and C viruses, but no transmission of human immunodeficiency virus among intravenous drug users participating in a syringe/needle exchange program. Scandinavian Journal of Infectious Diseases. 32(3):253–258. Mattick RP, Breen C, Kimber J, Davoli M. 2003a. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. The Cochrane Database of Systematic Reviews. (2):CD002209. Mattick RP, Kimber J, Davoli M. 2003b. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. The Cochrane Database of Systematic Reviews. (2):CD002207. Maude-Griffin PM, Hohenstein JM, Humfleet GL, Reilly PM, Tusel DJ, Hall SM. 1998. Superior efficacy of cognitive-behavioral therapy for crack cocaine abusers: Main and matching effects. Journal of Consulting and Clinical Psychology. 66:832–837. Mayet S, Farrell M, Ferri M, Amato L, Davoli M. 2004. Psychosocial treatment for opiate abuse and dependence. Cochrane Database of Systematic Reviews. (4):CD004330. McCance-Katz EF, Rainey PM, Friedland G, Kosten TR, Jatlow P. 2001. Effect of opioid dependence pharmacotherapies on zidovudine disposition. American Journal of Addictions. 10(4):296–307. McCance-Katz EF, Rainey PM, Friedland G, Jatlow P. 2003. The protease inhibitor lopinavirritonavir may produce opiate withdrawal in methadone-maintained patients. Clinical Infectious Diseases. 37(4):476–482. McCance-Katz EF, Rainey PM, Smith P, Morse GD, Friedland G, Boyarsky B, Gourevitch M, Jatlow P. 2006. Drug interactions between opioids and antiretroviral medications: Interaction between methadone, LAAM, and delavirdine. American Journal on Addictions. 15(1):23–34. McCoy CB, Rivers JE, McCoy HV, Shapshak P, Weatherby NL, Chitwood DD, Page JB, Inciardi JA, McBride DC. 1994. Compliance to bleach disinfection protocols among injecting drug users in Miami. Journal of Acquired Immune Deficiency Syndromes. 7(7):773–776. McKay JR, Alterman AI, Cacciola JS, Rutherford MJ, O’Brien CP, Koppenhaver J. 1997. Group counseling versus individualized relapse prevention aftercare following intensive outpatient treatment for cocaine dependence. Journal of Consulting and Clinical Psychology. 65:778–788. McLellan AT, Arndt IO, Metzger DS, Woody GE, O’Brien CP. 1993. The effects of psychosocial services in substance abuse treatment. Journal of the American Medical Association. 269(15):1953–1959. McLellan T, Lewis D, O’Brien C, Kleber H. 2000. Drug dependence, a chronic mental illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association. 284(13):1689–1695. Minozzi S, Amato L, Vecchi S, Davoi M, Kirchmayer U, Verster A. 2006. Oral naltrexone maintenance treatment for opioid dependence. The Cochrane Database of Systematic Reviews. (1):CD001333. Moatti JP, Carrieri MP, Spire B, Gastaut JA, Cassuto JP, Moreau J, Manif 2000 study group. 2000. Adherence to HAART in French HIV-infected injecting drugs users: The contribution of buprenorphine drug maintenance treatment. AIDS. 14(2):151–155. Monti PM, Rohsenow DJ, Michalec E, Martin RA, Abrams DB. 1997. Brief coping skills treatment for cocaine abuse: Substance abuse outcomes at three months. Addiction. 92:1717–1728. Moss AR, Vranizan K, Gorter R, Bacchetti P, Watters J, Osmond D. 1994. HIV seroconversion in intravenous drug users in San Francisco, 1985-1990. AIDS. 8(2): 223–231.

OCR for page 1
Needle RH, Burrows D, Friedman SR, Dorabjee J, Touze G, Badrieva L, Grund J-PC, Kumar MS, Nigro L, Manning G, Latkin C. 2005. Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users. International Journal of Drug Policy. 16(Suppl 1):S45–S57. NIDA (National Institute on Drug Abuse). 2002. Principles of HIV Prevention in Drug-Using Populations: A Research-Based Guide. Washington, DC: NIDA. [Online]. Available: http://www.nida.nih.gov/POHP/FAQ_1.html [accessed June 22, 2006]. NRC (National Research Council) and IOM (Institute of Medicine). 1995. Preventing HIV Transmission: The Role of Sterile Needles and Bleach. Washington, DC: National Academy Press. O’Brien C, Kampman K. 2004. Opioids: Antagonists and partial agonists. In: The American Psychiatric Association Textbook of Substance Abuse Treatment. 3rd edition. Washington, DC: American Psychiatric Press, Inc. Pp. 305–319. Patrick DM, Strathdee SA, Archibald CP, Ofner M, Craib KJ, Cornelisse PG, Schechter MT, Rekart ML, O’Shaughnessy MV. 1997. Determinants of HIV seroconversion in injection drug users during a period of rising prevalence in Vancouver. International Journal of STDs and AIDS. 8(7):437–445. Peirce JM, Petry NM, Stitzer ML, Blaine J, Kellogg S, Satterfield F, Schwartz M, Krasnansky J, Pencer E, Silva-Vazquez L, Kirby KC, Royer-Malvestuto C, Roll JM, Cohen A, Copersino ML, Kolodner K, Li R. 2006. Effects of lower-cost incentives on stimulant abstinence in methadone maintenance treatment: A national drug abuse treatment clinical trials network study. Archives of General Psychiatry. 63(2):201–208. Petry NM, Tedford J, Austin M, Nich C, Carroll KM, Rounsaville BJ. 2004. Prize reinforcement contingency management for treating cocaine users: How low can we go, and with whom? Addiction. 99:349–360. Piotrowski NA, Tusel DJ, Sees KL, Reilly PM, Banys P, Meek P, Hall SM. 1999. Contingency contracting with monetary reinforcers for abstinence from multiple drugs in a methadone program. Experimental and Clinical Psychopharmacology. 7(4):399–411. Pollack H, Heimer R. 2004. Impact and cost-effectiveness of methadone maintenance programs for HIV and hepatitis C prevention. In: Jager J, Limburg W, Kretzschmar M, Postma M, Wiessing L, eds. Hepatitis C and Injecting Drug Use: Impact, Costs, and Policy Options. Lisbon: European Monitoring Centre for Drugs and Drug Addiction. 7:345–371. Porter J, Metzger D, Scotti R. 2002. Bridge to services: Drug injectors’ awareness and utilization of drug user treatment and social service referrals, medical care, and HIV testing provided by needle exchange programs. Substance Use and Misuse. 37(11):1305–1330. Prendergast ML, Urada D, Podus D. 2001. Meta-analysis of HIV risk reduction interventions with drug abuse treatment programs. Journal of Consulting and Clinical Psychology. 69(3):389–405. Quan VM, Chung A, Abdul-Quader AS. 1998. The feasibility of a syringe-needle exchange program in Vietnam. Substance Use and Misuse. 33(5):1055–1067. Riley ED, Wu AW, Junge B, Marx M, Strathdee SA, Vlahov D. 2002. Health services utilization by injection drug users participating in a needle exchange program. American Journal of Drug and Alcohol Abuse. 28(3):497–511. Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee SA. 2005. The social structural production of HIV risk among injecting drug users. Social Science Medicine. 61(5):1026– 1044. Roozen HG, Boulogne JJ, van Tulder MW, van den Brink W, De Jong CAJ, Kerkhof AJFM. 2004. A systematic review of the effectiveness of the community reinforcement approach in alcohol, cocaine and opioid addiction. Drug and Alcohol Dependence. 74:1–13.

OCR for page 1
Samet JH, Friedmann P, Saitz R. 2001. Benefits of linking primary medical care and substance abuse services: Patient, provider, and societal perspectives. Archives of Internal Medicine. 161:85–91. Sarkar K, Mitra S, Bal B, Chakraborty S, Bhattacharya SK. 2003. Rapid spread of hepatitis C and needle exchange programme in Kolkata, India. Lancet. 361(9365):1301–1302. Schechter MT, Strathdee SA, Cornelisse PG, Currie S, Patrick DM, Rekart ML, O’Shaughnessy MV. 1999. Do needle exchange programmes increase the spread of HIV among injection drug users?: An investigation of the Vancouver outbreak. AIDS. 13(6):F45–F51. Schottenfeld RS, Chawarski MC, Pakes JR, Pantalon MV, Carroll KM, Kosten TR. 2005. Methadone versus buprenorphine with contingency management or performance feedback for cocaine and opioid dependence. American Journal of Psychiatry. 162(2): 340–349. Sees KL, Delucchi KL, Masson C, Rosen A, Clark HW, Robillard H, Banys P, Hall SM. 2000. Methadone maintenance versus 180-day psychosocially enriched detoxification for treatment of opioid dependence: A randomized controlled trial. Journal of the American Medical Association. 283(10):1303–1310. Semaan S, Des Jarlais DC, Sogolow E, Johnson WD, Hedges LV, Ramirez G, Flores SA, Norman L , Sweat MD, Needle R. 2002. A meta-analysis of the effect of HIV prevention interventions on the sex behaviors of drug users in the United States. Journal of Acquired Immune Deficiency Syndromes. 30(Suppl 1):S73–S93. Serpellini G, Carrieri MP. 1994. Methadone treatment as a determinant of HIV risk reduction among injecting drug users: A nested case-control study. AIDS Care. 6(2):215–220. Shoptaw S, Reback CJ, Peck JA, Yang Xiaowei, Rotheram-Fuller E, Larkins S, Veniegas RC, Freese TE, Hucks-Ortiz C. 2005. Behavioral treatment approaches for methamphetamine dependence and HIV-related sexual risk behaviors among urban gay and bisexual men. Drug and Alcohol Dependence. 78:125–134. Shoptaw S, Huber A, Peck J, Yang X, Liu J, Dang J, Roll J, Shapiro B, Rotheram-Fuller E, Ling W. 2006. Randomized, placebo-controlled trial of sertraline and contingency management for the treatment of methamphetamine dependence. Drug and Alcohol Dependence. [Epub available online April 18, 2006]. Strain EC et al. 1993. Dose-response effects of methadone in the treatment of opioid dependence. Annals of Internal Medicine. 119:23–27. Strathdee SA, Patrick DM, Currie SL, Cornelisse PG, Rekart ML, Montaner JS, Schechter MT, O’Shaughnessy MV. 1997. Needle exchange is not enough: Lessons from the Vancouver injecting drug use study. AIDS. 11(8):F59–F65. Strathdee SA, Celentano DD, Shah N, Lyles C, Stambolis VA, Macalino G, Nelson K, Vlahov D. 1999. Needle-exchange attendance and health care utilization promote entry into detoxification. Journal of Urban Health. 76(4):448–460. Taylor A, Goldberg D, Hutchinson S, Cameron S, Gore SM, McMenamin J, Green S, Pithie A, Fox R. 2000. Prevalence of hepatitis C virus infection among injecting drug users in Glasgow 1990-1996: Are current harm reduction strategies working? Journal of Infectious Diseases. 40(2):176–183. Tennant FS, Rawson RA, Cohen AJ, Mann A. 1984. Clinical experience with naltrexone in suburban opioid addicts. Journal of Clinical Psychiatry. 45(9 pt 2):42–45. UNAIDS (Joint United Nations Programme on HIV/AIDS). 2006. 2006 Report on the Global AIDS Epidemic: A UNAIDS 10th Anniversary Special Edition. Geneva, Switzerland: UNAIDS. UNODC (United Nations Office on Drugs and Crime). 2005. 2005 World Drug Report. Vienna, Austria: UNODC.

OCR for page 1
Vanichseni S, Wongsuwan B, Choopanya K, Wongpanich K. 1991. A controlled trial of methadone maintenance in a population of intravenous drug users in Bangkok: Implications for prevention of HIV. The International Journal of Addictions. 26(12):1313– 1320. Washton AM, Pottash AC, Gold MS. 1984. Naltrexone in addicted business executives and physicians. Journal of Clinical Psychiatry. 45(9 pt 2):39–41. WHO (World Health Organization). 2004a. Evidence for Action: Effectiveness of Community-Based Outreach in Preventing HIV/AIDS Among Injecting Drug Users. Geneva, Switzerland: WHO. WHO. 2004b. Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: Guidelines on Care, Treatment and Support for Women Living with Hiv/Aids and Their Children in Resource-Constrained Settings. Geneva, Switzerland: WHO. WHO. 2005a. Evidence for Action: Effectiveness of Drug Dependence Treatment in Preventing HIV Among Injecting Drug Users. Geneva, Switzerland: WHO. WHO. 2005b. Policy and Programming Guide for HIV/AIDS Prevention and Care Among Injecting Drug Users. Geneva, Switzerland: WHO. WHO. 2005c. WHO Model List of Essential Medicine. 14th edition. [Online]. Available: http://whqlibdoc.who.int/hq/2005/a87017_eng.pdf [accessed August 11, 2006]. WHO, UNODC, UNAIDS. 2004. Substitution Maintenance Therapy in the Management of Opioid Dependence and HIV/AIDS Prevention: Position Paper. Geneva, Switzerland: WHO. Wiebel WW, Jimenez A, Johnson W, Ouellet L, Jovanovic B, Lampinen T, Murray J, O’Brien MU. 1996. Risk behavior and HIV seroincidence among out-of-treatment injection drug users: A four-year prospective study. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 12(3):282–289. Williams AB, McNelly EA, Williams AE, D’Aquila RT. 1992. Methadone maintenance treatment and HIV type 1 seroconversion among injecting drug users. AIDS Care. 4(1): 35–41.