HIV This Week

Couple-based HIV prevention for low-income drug users from New York City: a randomized controlled trial to reduce dual risks

El-Bassel N, Gilbert L, Wu E, Witte SS, Chang M, Hill J, Remien RH. J Acquir Immune Defic Syndr 2011.

Dual threats of injection drug use and risky sexual practices continue to increase transmission of HIV and other sexually transmitted infections (STIs) among drug-using couples in low-income communities in the United States. To date, no effective HIV prevention interventions have focused exclusively on this population. Using a randomized controlled trial, 282 HIV-negative drug-using couples (564 individuals) were randomly assigned to receive either: (1) couple-based Risk Reduction; (2) individual-based HIV Risk Reduction, or (3) couple-based Wellness Promotion, which served as an attention control condition. Two hypotheses were tested: (1) “Intervention Effect”--whether the HIV risk reduction intervention provided to the couple or individual partners would be more efficacious in decreasing the number of unprotected sexual acts and having a lower cumulative incidence of biologically confirmed STIs over the 12-month follow-up period compared to the attention control condition; and (2) “Modality Effect”--whether the HIV Risk Reduction intervention would be more likely to decrease the number of unprotected sexual acts and have a lower cumulative STI incidence when delivered to a couple compared to the same intervention delivered to an individual. Over the 12-month follow-up, there was a 30% reduction in the incidence rate of unprotected acts of intercourse with the study partners compared to participants in the attention control arm. Over the12-month follow-up, there was a 29% reduction in the same outcome in the couple arm compared to the individual arm with a 41% reduction at the 12-month follow up. Thus, a couple-based approach that addresses drug and sexual risks and targets low-income, active drug users may help curb the HIV epidemic.

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Editor’s note: It makes sense that the unit of change in reducing HIV risk within heterosexual couples is the couple itself—what is known as a ‘dyadic focus’. Most couple-based research has focused on serodiscordant couples in which one member has HIV infection or on seroconcordant couples in which both members are living with HIV. This is the first randomised controlled trial to test the effectiveness of a couple-based HIV prevention programme for drug-using HIV-negative couples. To be eligible for the trial, HIV-negative couples had to have been together for at least 6 months, have at least one member who had used illicit drugs in the previous 90 days and was either seeking or was in drug treatment, and have had unprotected sexual intercourse with each other in the previous 90 days. Most were recruited through street outreach (homeless shelters, soup kitchens, needles/syringe programmes, and word-of-mouth). The majority were homeless and active crack cocaine users, a population usually excluded from clinical trials. The couple-based risk reduction programme, which was relationship oriented, focused on couple communication, negotiation, problem-solving, disclosure, improving condom skills, and enhancing couple motivation. Not surprisingly, it resulted in less unprotected sex within couples than either the same risk reduction programme delivered to only one partner or a couple wellness programme focused on improving diet, fitness, disease screening, and stress-reduction. Replicating the findings and scaling up this approach for drug-involved couples are the next steps.

Opioid substitution therapy in Manipur and Nagaland, north-east India: operational research in action

Armstrong G, Kermode M, Sharma C, Langkham B, Crofts N. Harm Reduct J. 2010 Dec 1;7(1):29.

There is good evidence for the effectiveness of opioid substitution therapy for people who inject drugs in middle- and high-income countries but little evidence regarding the provision of opioid substitution therapy by non-government organisations in resource-poor settings. This paper reports on outcomes of an non-government organisation-based opioid substitution therapy programme providing sub-lingual buprenorphine to opiate dependent people who inject drugs in two north-east Indian states (Manipur and Nagaland), a region where conflict, under-development and injecting of heroin and Spasmoproxyvon are ongoing problems. The objectives of the study were: 1) to calculate opioid substitution therapy treatment retention, 2) to assess the impact on HIV risk behaviours and quality of life, and 2) to identify client characteristics associated with cessation of treatment due to relapse. This study involves analysis of data that were routinely and prospectively collected from all clients enrolled in an opioid substitution therapy programme in Manipur and Nagaland between May 2006 and December 2007 (n=2569, 1853 in Manipur and 716 in Nagaland) using standardised questionnaires, and is best classified as operational research. The data were recorded at intake into the programme, after three months, and at cessation. Outcome measures included HIV risk behaviours and quality of life indicators. Predictors of relapse were modelled using binary logistic regression. Of all clients enrolled in opioid substitution therapy during the month of May 2006 (n=713), 72.8% remained on treatment after three months, and 63.3% after six months. Statistically significant (p = 0.05) improvements were observed in relation to use of unsterile equipment, unsafe sex, incidents of detention, and a range of quality of life measures. Greater spending on drugs at intake (OR 1.20), frequently missing doses (OR 8.82), and having heroin rather than Spasmoproxyvon as the most problematic drug (OR 1.95) were factors that increased the likelihood of relapse, and longer duration in treatment (OR 0.76) and regular family involvement in treatment (OR 0.20) reduced the likelihood of relapse. The findings from this operational research indicate that the provision of opioid substitution therapy by non-government organisations in the severely constrained context of Manipur and Nagaland achieved outcomes that are internationally comparable, and highlights strategies for strengthening similar programmes in this and other resource-poor settings.

Abstract:

Editors’ note: The comprehensive package of nine core interventions recommended by UNAIDS, UNODC, and WHO for prevention and treatment for people who inject drugs includes opioid substitution therapy – the substitution of orally administered opiates such as buprenorphine and methadone for illicit drugs. This study, conducted in Manipur and Nagaland where approximately 2% of the population inject drugs, is an example of classic operational research to assess effectiveness of a community-based programme operating out of drop-in centres rather than on the confines of a randomised controlled trial. The programme itself was funded at various times by the Bill and Melinda Gates Foundation, the UK Department for International Development, the National AIDS Control Organisation, and Emmanuel Hospital Association. At one year, 50.8% of enrolled clients remained on treatment and 12.8% had completed the programme. There were substantial decreases in drug use and HIV risk behaviours, accompanied by less family conflict, fewer episodes of detention or imprisonment, less work-related absenteeism for those with jobs, increased attendance at social events, and improved self-reported quality of life. Clearly the programme has proven its worth – now the challenge is to see if these results can be replicated in other settings and to assess different strategies to improve retention in the programme – some people will need methadone for life.

Sex, drugs and economic behaviour in Russia: a study of socio-economic characteristics of high risk populations

Wall M, Schmidt E, Sarang A, Atun R, Renton A. Int J Drug Policy. 2010 Nov 3.

Russia faces a worsening HIV epidemic among people who inject drugs. This paper examines the social and economic characteristics of injecting drug users in two cities in Russia and compares this with the general population to explore their social and economic needs and the wider implications of the epidemic for the economy and society. The research team did a cross sectional survey of 711 people who inject drugs in two Russian cities (Volgograd and Barnaul), recruited by a modified chain referral sampling method. Respondents were asked about their education, work, living conditions, expenditure on goods and services and livelihoods. Their characteristics were compared with a random sample of the general population. There are a number of characteristics in which people who inject drugs do not differ systematically from the general population. They have general education; live in the towns where they were born; and their monthly income is comparable with the Russian average. However, people who inject drugs are more likely to have a vocational qualification than a university degree; less likely to have a permanent job; and those employed are skilled manual rather than professional workers. People who inject drugs are less likely to be officially married and more likely to be living with their parents or on their own. The majority rely on financial help from relatives or friends; and much of their income is from illegal or semi-legal activities. People who inject drugs are not atypical or marginal to the Russian economy and society. However, their drug-dependency and related life-style make them particularly vulnerable to the impact of poverty, violence and social insecurity. A failure to effectively control the dual IDU/HIV epidemic can have a significant negative impact on the Russian labour force, health and social costs and overall economy.

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Editors’ note: This study of 700 street-recruited people who had injected drugs in the previous 30 days was restricted to two Russian cities, Volgograd in Southern Russia and Barnaul in Siberia. Its results, comparing their social and economic profiles with those of the general population in Russia, go a long way to countering the common belief that Russians who inject drugs come from disadvantaged and broken families or are migrants from other countries of the former Soviet Union. Overall, 86% were born in the region where they now lived, 75% had not moved house and 14% had moved house only once in the preceding 2 years, and 95% had formal registration with local authorities (propiska) entitling them to state-funded health care and social services. They were more likely to have vocational training and less likely to have completed higher education than the general population; 35% had regular jobs, compared to 51% of the general population, with the construction sector (carpenters, joiners, decorators) predominating. With the Russian economy experiencing a demographic crisis due to high alcohol consumption, low birth rates, and high mortality among men, shortages of workers with vocational qualifications are predicted. Unless harm reduction and antiretroviral treatment access are significantly expanded for people who inject drugs in Russia (estimated at 1.5-3 million), their HIV-related morbidity and mortality are likely to affect the future Russian labour force.

IDU perspectives on the design and operation of North America's first medically supervised injection facility

Small W, Ainsworth L, Wood E, Kerr T. Subst Use Misuse. 2010 Sep 27. [Epub ahead of print]

While the public health benefits of supervised injection facilities (SIFs) have been well documented, there is lack of research examining the views of people who inject drugs regarding the operation of these facilities. This study used 50 semistructured qualitative interviews to explore the perspectives of people who inject drugs on the design and operation of a supervised injection facility in Vancouver, Canada. Although the environment and operation of the supervised injection facility are well accepted, long wait times and limited operating hours, as well as regulations that prohibit sharing drugs and assisted injections, pose barriers to using the supervised injection facility. Modifying operating procedures and expanding the capacity of the current facility could address these barriers.

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Editors’ note: The first officially sanctioned supervised injecting facility (SIF) opened in Switzerland in 1986. Until 2000, only Germany and the Netherlands had joined Switzerland in offering such services in major cities but, since 2000, SIFs have begun operating in Spain, Australia, Canada, Norway, and Luxembourg. They vary in hours, staffing, operating models, etc. but all include professional supervision of hygienic consumption of pre-obtained drugs with the goals of preventing overdose, reducing injecting-related transmission of HIV and other blood borne viruses, and providing an entry point to psychosocial and medical services. Unlike a study conducted in Montreal a decade ago to determine whether people who inject drugs would use a supervised injecting facility if it were to be created (Green et al 13^th IHRA conference Slovenia March 2002), this qualitative study gathered views on current functioning of the well-known Vancouver SIF ‘Insite’. Two major concerns voiced were the prohibition on sharing drugs, a prohibition that holds in most SIFs as it is deemed to constitute a form of trafficking, and a prohibition on assisted injecting. Individuals who require assistance to inject are by definition dependent on another person for their safe injection. Some SIFs acknowledge this vulnerability and are able to accommodate such individuals and their injectors. In other countries, some modification to the legal framework may be required to allow these individuals to benefit from this harm reduction service.