ReviewDrug abuse treatment as an HIV prevention strategy: a review
Introduction
In the United States as of the end of December 1998, 32% of the 679,739 adult/adolescent cases of AIDS have been linked to drug injection — either as the sole risk factor (20% of cases), concomitantly with male-to-male sexual contact (5% of cases), through heterosexual contact with an injecting drug user (5% of cases) or multiple exposure categories that include drug injection (2% of cases) (Centers for Disease Control and Prevention [CDC], 1998; Table 18, p. 28). The proportion of male AIDS cases attributable to the CDC-definition of ‘men who have sex with men’ has declined considerably in the last decade, while the proportion assigned to injection drug use has risen (Normand et al., 1995). Moreover, crack-cocaine users, who transmit HIV through their sexual behaviors, account for an increasing proportion of AIDS cases (Cohen et al., 1994). Choosing among the intervention strategies purported to prevent HIV in drug abusers is one of the most urgent questions facing health policy makers.
Drug abuse treatment is one approach that may have a strong impact on preventing HIV infection. Treatment has the potential to restrict the spread of HIV by reducing needle-use, a primary vector of HIV infection. If drug abuse treatment programs reduce injection practices that transmit HIV, they will have a direct effect in reducing the spread of HIV/AIDS. Many large-magnitude studies have shown that patients participating in methadone maintenance treatment (MMT), therapeutic communities, and outpatient drug-free programs decrease their drug use significantly (Simpson et al., 1979, Hubbard et al., 1989, Simpson, 1993), yet there is a need to examine the association between treatment and HIV risk behaviors such as sharing and re-use of needles.
Drug abuse treatment programs can also interrupt HIV transmission by decreasing risk behaviors related to sexual transmission of HIV, such as not using condoms. Drug abuse treatment programs see many people engaging in high risk sexual behaviors, including workers in the sex industry. If these programs are able to decrease high risk sexual practices among patients, they will also have a direct effect in reducing the spread of HIV/AIDS.
Drug treatment also has the potential to interrupt HIV transmission by promoting rehabilitation and serving as a platform for services such as HIV education and medical care. As early as 1986, policy groups called for all drug treatment programs to provide HIV transmission information (Inciardi, 1990). Federal regulations now require that the treatment admission process include HIV education (Drugs Used for Treatment of Narcotic Addicts, 1998). However, there have been mixed results in controlled trials of information and skills training (Auerbach et al., 1994). Other services can also be useful: For example, many programs have begun to offer primary medical care in drug abuse treatment (Selwyn et al., 1989, O’Connor et al., 1994). The recent development of HIV protease inhibitors adds optimism that HIV-infected people can postpone disease by adding protease inhibitors to their HIV treatment regimens (DeNoon, 1996). Offering medical care on-site at drug treatment programs helps patients receive appropriate medical treatment (Umbricht-Schneiter et al., 1994). Providing appropriate medical treatment can decrease patients' viral load and possibly their infectivity to others.
Thus, it is plausible that drug abuse treatment can have these powerful effects in preventing transmission of HIV, but how strong is the evidence that these preventive effects actually occur? Many reports have called for increasing the availability of drug abuse treatment in the United States to slow the spread of HIV (Public Health Service, 1988, Turner et al., 1989, Sisk et al., 1990). This expansion, however, has not occurred during the AIDS epidemic. To the contrary, the quality of treatment programs may actually be decreasing (D’Aunno and Vaughn, 1995, Etheridge et al., 1995). Further, there is debate about the conditions under which expanding drug abuse treatment is a cost-effective deterrent to the expanding HIV epidemic (Lampinen, 1991). This paper reviews recently published research evaluating the effect of drug abuse treatment in preventing HIV infection. Two earlier reviews have addressed this issue, though less methodically than the present study. Des Jarlais and colleagues reviewed the ‘hard data’ studies as of 1989 (Des Jarlais et al., 1990). They concluded that ‘bringing IV drug users into drug abuse treatment programs should be an effective method of protecting some of them from HIV infection’ (p. 51), and they sounded several qualifications about the necessity of having drug users enter treatment early in the expansion of HIV in a community and about the importance of retaining patients in treatment. Metzger et al. (1998) reviewed a variety of articles, published as early as 1984, concluding that drug users who are in treatment practice significantly lower rates of HIV risk behaviors, and ‘these self-reported behavioral differences are consistent with seroprevalence and seroincidence data’ (p. 102). In addition, Marsch (1998) published a meta-analysis on the efficacy of MMT as a pharmacotherapeutic agent in reducing drug use, HIV risks, and criminality. The present review extends these works by systematically reviewing the literature to understand how strong the evidence is that drug abuse treatment prevents HIV infection.
Section snippets
Search strategy and limitations
We conducted a search of the relevant English-language literature from 1988–1998 utilizing the databases MEDLINE and Psych/INFO, pairing keywords for modalities (drug abuse treatment, methadone, therapeutic community, detoxification, ambulatory care and drug abuse [outpatient drug-free is not a medical subject heading in MEDLINE]); with AIDS or HIV. We also searched both databases for articles by ten authors known to have conducted research in this area. In addition, our colleague, Michael
Conclusions
This review has identified 33 studies, with an aggregate of 17,771 subjects, published in peer-reviewed journals from 1988 to 1999. Twenty-eight of the 33 studies included MMT as a treatment modality, usually the only treatment modality, and 26 of the 28 studies showed positive results in reducing HIV infection and risk behaviors, including four studies of HIV seroconversion. In our opinion, the accumulated research provides sufficient evidence to conclude that MMT is a powerful tool to protect
Acknowledgements
Supported in part by Grants R01DA08753 and P5009253 from the National Institute on Drug Abuse. We appreciate the editorial suggestions of Drs Kevin Delucchi, Sharon M. Hall, and David Wasserman and the assistance of Dr Michael Prendergast in locating studies for this review.
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Present address: Department of Psychology, Louisiana State University, LA, USA.