Role of drug treatment and rehabilitation on HIV/AIDS prevention and care



  • Anita Palepu, Anita Raj, Nicholas J. Horton, et al. (2005). Substance abuse treatment and risk behaviours among HIV-infected persons with alcohol problems. Journal of Substance Abuse Treatment, Volume 28, Issue 1 , January, Pages 3-9.


We examined the association of substance abuse treatment with sexual and drug use risk behaviours among 349 HIV-infected persons with a history of alcohol problems using a standardized questionnaire regarding sexual and drug use risk behaviours, demographics, substance use, and use of substance abuse treatment. We defined substance abuse treatment services as any of the following in the past 6 months: 12 weeks in a half-way house or residential facility; 12 visits to a substance abuse counsellor or mental health professional; day treatment for at least 30 days; or participation in any methadone maintenance program. Our three outcome variables of high-risk behaviour were the Risk Assessment Battery sex-risk and drug-risk scores and high-risk sex behaviour which included any of the following: inconsistent condom use; having more than one sexual partner; and exchanging sex for money or drugs. Although sexual risk was high (51%) in our HIV-infected cohort, engagement in substance abuse treatment was not independently associated with lower frequency of any of our measures of high- risk behaviours. Although the opportunity exists to address HIV risk behaviours in the setting of substance abuse treatment, effective institutionalization of this challenging behaviour change effort has not yet been realized.


  • Appel, Philip W; Ellison, Aletha A; Jansky, Hadley K; Oldak, Rivka (2004) Barriers to enrollment in drug abuse treatment and suggestions for reducing them: opinions of drug injecting street outreach clients and other system stakeholders.   The American Journal Of Drug And Alcohol Abuse, Volume 30, Issue 1 , 2004, Pages 129-153.


Alcohol and other drug abuse (AOD) treatment is a major means of HIV/AIDS prevention, yet clients of street outreach programs (SOP) who are injection drug users (IDU), and outreach workers and staff as well, report various obstacles to enrolling clients in AOD programs. This study assessed the barriers to AOD enrollment facing high risk street outreach clients and obtained suggestions for reducing them. Data were obtained from semistructured field interviews with: 1) IDU outreach clients (N = 144) of the six SOPs in New York City (NYC) and northern suburbs supported by the Office of Alcoholism and Substance Abuse Services (OASAS), the single state agency in New York State for AOD prevention and treatment, 2) outreach workers and staff of the six SOPs (N = 55), 3) staff of detox and AOD treatment programs in major modalities treating IDUs (N = 71), and 4) officials and administrators (N = 11) in OASAS, the AIDS Institute of the Department of Health (addresses all aspects of the HIV/AIDS epidemic in New York State), and the agency for public assistance in New York City, the Human Resources Administration (HRA). Principal barriers for street outreach clients included personal-family issues, lack of insurance/Medicaid, ignorance, suspicion, and/or aversion to AOD treatment (methadone maintenance especially), "hassles" with Medicaid, lack of personal ID, lack of "slots," limited access to intake, homelessness, childcare-child custody issues. Further, about 18% had no desire for AOD services, reported no barriers, or were too enmeshed in addiction to enroll. Outreach staff cited prospective client's lack of ID and lack of Medicaid, lack of "slots," and stakeholder agency bureaucracy. Treatment staff cited lack of client readiness, "hassles" posed by welfare reform, AOD programs' own "red tape," waiting lists, and near exclusionary preference for the Medicaid-eligible. Finally, agency managers cited client factors, inadequate funding and lack of appropriate programs, treatment program requirements, and societal stigmatization of addicts. Proposed remedies included dropping ID and insurance requirements for admission, major increases in resources, funding the transporting of outreach client treatment candidates to AOD services sites, education and training initiatives, increased inter-agency cooperation, and the need for stakeholder agencies, OASAS especially, to more effectively integrate abstinence-oriented AOD services with harm reduction and the public health aspects of AOD problems.


  • Arthur Margolin, , S. Kelly Avants, Lara A. Warburton et al. (2003). A Randomized Clinical Trial of a Manual-Guided Risk Reduction Intervention for HIV-Positive Injection Drug Users. Health Psychology . Volume 22, Issue 2 , March 2003, Pages 223-228.


This study randomized 90 HIV-seropositive, methadone-maintained injection drug users (IDUs) to an HIV Harm Reduction Program (HHRP+) or to an active control that included harm reduction components recommended by the National AIDS Demonstration Research Project. The treatment phase lasted 6 months, with follow-ups at 6 and 9 months after treatment entry. Patients in both treatments showed reductions in risk behaviours. However, patients assigned to HHRP+ were less likely to use illicit opiates and were more likely to adhere to antiretroviral medications during treatment; at follow-up, they had lower addiction severity scores and were less likely to have engaged in high risk behavior. Findings suggest that enhancing methadone maintenance with an intervention targeting HIV-seropositive IDUs increases both harm reduction and health promotion behaviours.


  • A. R. Knowlton, D. R. Hoover, S. Chung, et al. (2001)  Access to medical care and service utilization among injection drug users with HIV/AIDS. Drug and Alcohol Dependence . Volume (Issue):  64(1) pp. 55-62.


Access to care and optimal service utilisation among 287 low income African-American former and current drug injectors was examined. Results indicated suboptimal outpatient care, and no evidence of alternative use of hospital services. Participation in drug treatment and case management were associated with greater access to care and use of outpatient services, even after controlling for current drug use, gender, and insurance. AIDS and physical functioning limitation were associated with emergency room (ER) use and hospitalisation. Participation in drug treatment and case management and an AIDS diagnosis were associated with optimal outpatient service use. Daily alcohol use was associated with ER as the usual facility for care. Integration of substance abuse treatment, case management, and medical services delivery may contribute to improved HIV care for this population. 


  • B. Lichtenstein, (1997). Women and crack-cocaine use: a study of social networks and HIV risk in an Alabama jail sample. Addiction Research . Volume (Issue):  5(4) pp. 279-296.


Although the crack-cocaine "epidemic' has been well documented in the USA, little is known about its prevalence in the rural south. Crime statistics, anecdotal evidence and drug treatment reports indicate that crack-cocaine use has emerged as a significant social phenomenon in Alabama (USA). The increase in paediatric and heterosexually-transmitted HIV/AIDS among African-Americans in Alabama suggests that the increase in crack-cocaine use and HIV/AIDS may be linked. This study sought to investigate the link between crack-cocaine use and HIV transmission in a small group of incarcerated Alabama women jailed for illicit drug use or drug-related crimes. The study was organised into focus group interviews consisting of three to six women (total 18), who discussed the topics of drug use, initiation and distribution, sexual activity, condom use and social networks in audiotaped sessions. The ratio of African-American to Caucasian women was 3:1, with ages ranging from 18 to 58 years. The use of crack-cocaine was said to be prompted by male intimates, with co-factors such as "rite of passage' (African-American women) and "life trauma' (Caucasian women) also reported. While drug distribution networks were primarily the domain of men, women reported being given more or better quality crack-cocaine and being assigned the role of purchaser for male friends and partners. Sexual exchange or barter was commonplace; however, condom use was sporadic or the prerogative of men. While condoms were most often used in sexual activity with strangers, they were rarely used in sex with friends or regular partners. Social networks consisted primarily of male intimates and men identified as "drug buddies'. Relationships between women were frankly distrustful and few subjects cited women as their friends. Relationships with family members were likely to be strained or fractured, with fathers reported as being absent or dead. The frequently cited finding that women who use crack-cocaine risk HIV transmission through unprotected sexual exchange is confirmed in this study. A broader investigation into the HIV-related risks associated with crack-cocaine use is recommended for both men and women in Alabama.


  • Carey, Michael P; Chandra, Prabha S; Carey, Kate B; Neal, Dan J (2003) Predictors of HIV risk among men seeking treatment for substance abuse in India.   Archives Of Sexual Behavior, Volume 32, Issue 4 , August 2003, Pages 339-349.


The purpose of this study was to investigate the prevalence and correlates of HIV risk among men receiving treatment for substance abuse in India. Consecutive inpatients from the major substance abuse hospital in southern India were screened using a structured interview and standardized measures to obtain demographic, psychiatric, sexual behavior, and substance use data at the time of admission. Seventy-seven percent of the 352 men who were screened reported that they were sexually active during the past year, and 13% reported that they had engaged in sexual practices associated with greater risk. The most common risk practices in the past year included having multiple sexual partners (7%), paying for sex (5%), and having unprotected anal sex (4%). Engaging in risky sexual practices was associated with the presence of a co-occurring psychiatric disorder and higher scores on a drug abuse screening measure. Assessing HIV risk in substance abuse settings can help to identify patients who may benefit from HIV-risk reduction programs. [Journal Article; In English; United States]


  • Craig, Robert J; Olson, Ronald E (2004) Predicting methadone maintenance treatment outcomes using the Addiction Severity Index and the MMPI-2 Content Scales (Negative Treatment Indicators and Cynism scales). The American Journal Of Drug And Alcohol Abuse, Volume 30, Issue 4 , November 2004, Pages 823-839


We studied the ability of the Minnesota Multiphasic Personality Inventory-2 Content Scales (Negative Treatment Indicators [TRT] and Cynicism [CYN]) and the domain scales of the Addiction Severity Index (ASI) in predicting outcome from a methadone maintenance program. Participants were 108 African American males treated in a VA health care outpatient methadone maintenance treatment program and followed for up to 1 year after admission. Dependent variables were 1) length of stay and the percentage of 2) missed medication days, 3) toxicology urine samples free from illicit drugs, 4) full-time employment, 5) attendance at scheduled counseling sessions, and 6) counselor ratings of patient progress. A stepwise linear regression equation indicated that low drug severity scores on the ASI and low scores on percentage of missed medication predicted patients who were clean 1 year later; low scores on the psychological domain of the ASI predicted attendance at counseling sessions; a discriminant function analysis (consisting of percent of missed medication, percentage of clean urines, and ratings of patient progress) successfully predicted patient status (i.e., dropouts vs. "active patients") with 85% accuracy. Although the TRT and CYN were related to some ASI domains, they were not associated with any outcome variable. Results suggest that some ASI scores serve as important indicators of patient progress in methadone maintenance treatment.


  • D. A. Himmelgreen & M. Singer, (1998). HIV, AIDS and other health risks: findings from a multisite study - an introduction. American Journal of Drug and Alcohol Abuse. Volume (Issue):  24(2) pp. 187-197.


In late 1990 the National Institute on Drug Abuse (NIDA) initiated the Cooperative Agreement (CA) for AIDS Community-Based Outreach/Intervention Research Program. The goal of this programme was to prevent the further spread of HIV among out-of-treatment drug users, in particular injection drug users (IDUs) and crack cocaine users, their sexual partners and those at risk for initiating injection behaviour. To accomplish this goal, the CA set out to monitor drug use and HIV risk behaviours, assess the efficacy of various HIV risk reduction interventions and develop and refine outreach and intervention strategies. Twenty-three research sites, 21 rural and urban sites in the United States and one each in Puerto Rico and Brazil, were included in the CA programme. This article presents an overview of the CA as well as a synopsis of the studies covered in this special issue examining the total CA database.


  • Dave Burrows, Franz Trautmann, Murdo Bijl & Yuri Sarankov (1999) Training in the Russian Federation on rapid assessment and response to HIV/AIDS among injecting drug users. Journal of Drug Issues . Volume (Issue):  29(4) pp. 811-842.


HIV is spreading quickly in several parts of the Russian Federation (RF), particularly among injecting drug users (IDUs). Prevention programmes have been established in several Russian cities to address these epidemics. Many more cities and regions need to respond quickly to the threat or occurrence of HIV spreading among IDUs. This paper describes the HIV situation and current response to HIV among IDUs in the RF, as well as describing the design, implementaion and processes of the first year of a training programme to assist health professionals and others to respond to the developing crisis. The discussion section of the paper centres on four broad themes that have emerged while implementing the training programme and the methods the authors have developed in the training programme to take account of these issues: the Russian Federation as "different' from other countries; local ways of making and using drugs; logistics in the Russian environment; and secrecy and competition. It concludes that this training programme may be considered by other countries in Central and Eastern Europe and elsewhere as an effective way to respond to HIV epidemics among IDUs.


  • D. D. Celentano, A. Mu oz, S. Cohn & D. Vlahov (2001). Dynamics of behavioral risk factors for HIV/AIDS: a 6-year prospective study of injection drug users. Drug and Alcohol Dependence. Volume (Issue):  61(3) pp. 315-322.


This prospective study of 2960 injection drug users investigated the dynamic nature of HIV behavioural risk factors between 1988 and 1994. Behavioural risks were assessed semi-annually. Robust regression models of time-dependent covariates were used to identify longitudinal predictors of behaviour change. Maintenance of risky behaviours varied over time, with risk reduction seen more among HIV infected participants thant among HIV seronegatives. Those at highest risk for HIV transmission were least likely to cease engaging in these behaviours. Interventions staged according to risk behaviours, targeting incremental risk reduction rather than only promoting abstinence, may be more successful in reducing HIV transmission among drug injectors. 


  • E. A. Wells, D. A. Calsyn, L. L. Clark, A. J. Saxon & T. R. Jackson,(1996)  Retention in methadone maintenance is associated with reductions in different HIV risk behaviors for women and men. American Journal of Drug and Alcohol Abuse , Volume (Issue):  22(4) pp. 509-521.


Using AIDS Initial Assessment questionnaire (AIA) data from 353 injection drug users (IDUs) newly admitted to methadone maintenance (MM), three dimensions of injection risk behavior ("sharing with sexual partner', "sharing with others', and "new needle use') were identified. Among IDUs who continued to inject drugs at one year, men retained in treatment obtained lower scores on the "sharing with others' scale than men not retained, even when controlling for initial scale scores and injection frequency. Associations between retention in MM and changes in sexual risk were examined using two AIA measures of sexual risk behavior ("number of IDU sexual partners' and "relative frequency of unprotected vaginal intercourse'). Controlling for injection frequency, prior sexual risk, and age, there was no difference in sexual risk for men retained in treatment versus those not retained. Among women, those who stayed in MM for one year reported significantly fewer IDU partners.

El-Bassel, Nabila; Gilbert, Louisa; Rajah, Valli (2003) The relationship between drug abuse and sexual performance among women on methadone. Heightening the risk of sexual intimate violence and HIV. Addictive Behaviors, Volume 28, Issue 8 , October 2003, Pages 1385-1403


PURPOSE: Through in-depth interviews with 38 women recruited from methadone maintenance treatment programs (MMTPs), this paper examines subjective experiences regarding the effects of illicit drugs on the women's sexual behavior and that of their male sexual partners, mainly changes in libido, performance, and pleasure. METHODS: This paper addresses several questions: (1) How does drug use affect women's sexual performance? (2) How does drug use affect their partners' sexual performance and the sexual dynamics in their relationship? (3) How does drug use affect these women and their partners differently? (4) How are sexual disparities between women and their partners, heightened by drug use, linked with sexual and physical violence and risk of HIV. RESULTS: Three major themes are discussed: some women believe that drugs, particularly heroin, increase their sexual performance, libido, and pleasure, but for others, drugs, particularly crack cocaine, inhibit their sexual performance and desire. Many of the women believe that crack cocaine and heroin enhance a man's sexual desire, performance, and pleasure. However, other women deem that these drugs are responsible for their partners' abusive and coercive behavior. The data further indicate that gender disparities, in how crack cocaine and heroin affect the sexual dynamics between drug-involved couples, often lead to sexual coercion and physical abuse. CONCLUSION: This in-depth narrative study of abused women in MMTPs draws implications from their subjective experiences for understanding the contextual mechanisms linking drug use, intimate sexual abuse, and HIV risk. It also suggests implications for designing HIV prevention programs that take into account the differential effects of drugs on sexual intimate violence and HIV risk. Education about the effects of drugs on sexuality and on the risks of sexual violence and HIV transmission is crucial for drug-involved women.


  • Flanzer J. (2003). Health services research: drug use and human immunodeficiency virus in the United States. Clin Infect Dis . Dec 15;37 Suppl 5:S439-44.


Major research findings show gaps in health services research on the prevalence and outcomes of patient- and organization-level human immunodeficiency virus (HIV) and drug abuse prevention and treatment services. The latest thrust of health services research on translational research issues includes informing and training practitioners about new, proven drug abuse treatment interventions; changing treatment organizations (creating a climate for change and building a culture to sustain change); and financing new treatments. Findings defining the direct relationship between the quality of drug abuse treatment and the patients' program completion, the perception of the staff by the patient, feelings of self-empowerment and mitigation of patient and organizational readiness, the superiority of integrated care, and the primary reasons for delays in HIV-infected substance-using patients seeking care are included. More needs to be done to increase the participation of substance abuse programs in teaching about and implementing HIV prevention and developing means to modulate or eliminate barriers to the integration of HIV and substance abuse care.


  • F. I. Bastos, M. de Fatima de Pina & C. L. Szwarcwald, (2002). The social geography of HIV/AIDS among injection drug users in Brazil. International Journal of Drug Policy . Volume (Issue):  13(2) pp. 137-144.


The paper addresses the socio-geographical spread of HIV/AIDS among injection drug users (IDUs) in Brazil, highlighting patterns and trends of the epidemic in different Brazilian regions. Data relative to the Southeast are reviewed and original analyses for the South are presented. The results indicate that the epidemic is diminishing in the Southeast, after a significant increase in the late 1980s, following major cocaine trafficking routes. On the other hand, the AIDS epidemic is far from levelling off in the South. In this region, IDUs have been pivotal in the dynamics of the epidemics. This explains, at least partially, the recent spread in the South, affecting a large number of women, most of them partners of IDUs, and their offspring, and contributing for a less significant decline of AIDS related deaths, when compared with other Brazilian regions.


  • F. I. Bastos, S. A. Strathdee, M. Derrico & M. de Fatima Pina, (1999). Drug use and the spread of HIV/AIDS in South America and the Caribbean. Drugs: education, prevention and policy. Volume (Issue): 6(1) pp. 29-49.


The authors review available data on drug use with respect to the spread of HIV/AIDS in South America and the Caribbean. Although many information gaps remain, the emerging picture clearly shows the significant role of both injected cocaine and crack cocaine in the Brazilian epidemic and the increasingly large role of injecting cocaine in the Southern Cone. The Caribbean and the Andean regions are thus far spared from extensive diffusion of injecting drugs and its consequences. However, these regions are now experiencing a significant transition, in terms of an increasing role of crack cocaine in the Caribbean HIV/AIDS epidemic and the recent introduction of heroin and initiation of drug injection in the Andean region. Harm-reduction strategies are being implemented for the first time in recent years after a long delay, but remain primarily restricted to Brazil and to a lesser extent, Argentina. Yet even in these settings, harm-reduction programmes such as needle-exchange programmes face considerable challenges with respect to restrictive legislation and lack of broader support. 


  • G. A. D. Smereck & E. M. Hockman,(1998). Prevalence of HIV infection and HIV risk behaviors associated with living place: on-the-street homeless drug users as a special target population for public health intervention. American Journal of Drug and Alcohol Abuse . Volume (Issue):  24(2) pp. 299-319.


The study described here examined the prevalence of HIV infection as a function of place of residence and high-risk behaviours in six subpopulations of out-of-treatment drug injectors and crack cocaine users who participated in the National Institute on Drug Abuse (NIDA) Cooperative Agreement project. The subpopulations were blacks, Hispanics and non-Hispanic whites sampled separately by gender. The research asked three questions: (1) is the HIV infection rate higher among the on-the-street homeless than among those in other places of residence; (2) do high-risk drug-related behaviours differ by housing status; and (3) what are the joint effects of high-risk drug-related behaviours and housing status on the probability of HIV infection? Overall, on-the-street homeless had a significantly higher HIV+ rate (19.0 percent) than the study population as a whole (11.2 percent). Rates differed by gender and race, with exceptionally high HIV+ rates for on-the-street homeless Hispanic males (29 percent) and females (32 percent) and for on-the-street homeless black females (38 percent). Having used drug works previously used by a HIV-infected person was a strong predictor of HIV+ status, as was frequency of drug injections and crack use. Having multiple sex partners was also a significant risk behaviour. Findings argue against considering on-the-street homelessness as equivalent to shelter dwelling or aggregated homelessness for purposes of the AIDS epidemic. On-the-street homeless drug users were at strong risk for acquisition and transmission of HIV infection and therefore in need of targeted - racially relevant, ethnically relevant and gender-relevant - public health interventions to help prevent the spread of AIDS. 


  • G. A. Dingle & T. P. S. Oei (1997) Is alcohol a cofactor of HIV and AIDS? Evidence from immunological and behavioral studies. Psychological Bulletin . Volume (Issue):  122(1) pp. 56-71.


The authors aim to critically examine empirical research on the effects of alcohol on HIV and AIDS from the immunological and behavioural fields. In virtro immunological studies demonstrate that social drinking increases the susceptibility of human cells to HIV infection. Animal studies show that acute and chronic alcohol ingestion increases rate of progression from retrovirus to clinical illness. In humans with HIV, no experimental evidence shows that alcohol is a cofactor of AIDS. Findings from behavioural studies show that a link between social drinking and risk of HIV is weak. No experimental evidence demonstrates that chronic drinking influences rate and course of disease progression to AIDS in humans who are HIV+. It is premature to promote the role of alcohol as a cofactor in HIV and AIDS. 


  • G. M. McClelland, L. A. Teplin, K. M. Abram & N. Jacobs (2002) HIV and AIDS risk behaviors among female jail detainees: implications for public health policy. American Journal of Public Health . Volume (Issue):  92(5) pp. 818-825.


The authors examined the sexual and injection drug use HIV and AIDS risk behaviours of female jail detainees. The sample (n = 948) was stratified by charge type (felony vs misdemeanour) and race/ethnicity (African-American, non-Hispanic white, Hispanic, other). Non-Hispanic white women, women arrested for less serious charges, women who had prior arrests, women arrested on drug charges, and women with severe mental disorders were at especially high risk for sexual and injection drug transmission of HIV and AIDS. Many women at risk for HIV and AIDS-women who use drugs, women who trade sex for money or drugs, homeless women, and women with mental disorders-eventually will cycle through jail. Because most jail detainees return to their communities within days, providing HIV and AIDS education in jail must become a public health priority. 


  • G. P. Falkin & S. M. Strauss (2000) Drug-using women's communication with social supporters about HIV/AIDS issues. Journal of Drug Issues . Volume (Issue):  30(4) pp. 801-822.


Communication about health issues such as HIV/AIDS is essential for people, especially women, to obtain the social support they need either to prevent illness or manage it. This article compares the kinds of HIV-related issues that HIV positive and HIV negative substance-abusing women (N = 211) in New York City talk about with various types of supporters. Despite the stigma associated with AIDS and their unconventional lifestyles, both groups of women talked to a broad spectrum of supporters about a variety of HIV-related issues, though this was more the case for HIV positive women. Although the main topic that both groups discussed with their supporters was their HIV status, the women also talked about risk reduction, their supporters' HIV status, HIV testing, how to live with AIDS, information about HIV/AIDS, and the emotional impact of AIDS (e.g., fear of infection, reactions to learning test results, and the impact of knowing others who have died from the disease).


  • Hagan H, Thiede H, Des Jarlais DC. (2005) HIV/hepatitis C virus co-infection in drug users: risk behavior and prevention. AIDS, Oct;19 Suppl 3:S199-S207.


Studies of HIV-positive patients have consistently shown that drug users, in particular injection drug users (IDU), are far more likely to have hepatitis C virus (HCV) infection than other patient groups. HIV incidence and prevalence in IDU has declined in recent years, but HCV remains endemic in this population. HCV antibody prevalence among non-injection users of drugs such as heroin and cocaine is between 5 and 30%, although there are scant data on specific transmission risk behavior. The control of HIV/HCV co-infection must address HCV prevention. Epidemiological studies have suggested that HCV prevalence in IDU is subject to various influences, some of which may be modifiable by interventions. However, studies have not shown consistent effects of various prevention strategies on HCV transmission, including studies of HCV screening and education, drug treatment or needle exchange. Although some large cross-sectional studies in regions where needle exchange is available to a large number of drug injectors have reported declining HCV prevalence, the scale of services needed is a matter of considerable debate and has not been systematically quantified. Priorities for research related to the prevention of HIV/HCV co-infection should include estimating the effect on disease occurrence of eliminating specific risk factors, and specifying the level of resources needed to alter HCV incidence.


  • Hammett TM; Johnston P; Kling R; Liu W; Ngu D (2005) Correlates of HIV status among injection drug users in a border region of southern China northern Vietnam. JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2005 Feb 1;38(2):228-235


This article presents an analysis of the correlates of HIV status among samples of injection drug users (IDUs) in Lang Son Province, Vietnam (n = 348), and Ning Ming County, Guangxi Province, China (n = 294), who were interviewed and tested for HIV antibody just before the start of a peer-based HIV prevention intervention in this border region. Participants were largely male, in their 20s, and single. Logistic regression analysis suggests that among Chinese IDUs, border-related factors (eg, living closer to the border, buying drugs across the border more frequently) and younger age are the best predictors of HIV positivity. In Vietnam, HIV status seems to drive behavior (eg, some risk reduction practices are predictive of HIV positivity). These differing patterns may reflect the fact that the intertwined epidemics of heroin injection and HIV began earlier and HIV prevalence has reached significantly higher levels in Lang Son than across the border in Ning Ming. Although border-related factors emerge as predictors in Ning Ming, more IDUs in Lang Son are HIVpositive and may be reacting behaviorally to that status. Their greater likelihood of engaging in risk reduction measures may reflect some combination of a belief that risk reduction can slow disease progression and an altruistic desire to avoid infecting others.


  • Huckans MS, Blackwell AD, Harms TA, et al. (2005) Integrated hepatitis C virus treatment: addressing comorbid substance use disorders and HIV infection. AIDS, Oct;19 Suppl 3:S106-S115.


OBJECTIVES: To examine hepatitis C virus (HCV) and HIV testing patterns within the Northwest Veterans Integrated Service Network (VISN 20). METHODS:: Using a comprehensive VISN 20 database, we retrospectively reviewed medical records of 293 445 veterans. RESULTS:: 32.8% of patients were tested for HCV, 5.5% were tested for HIV, and 4.3% were co-tested. Of those tested, 12.3% were HCV positive, 5.4% were HIV positive, and 1.6% were co-infected. 79.1% of HIV-positive patients were tested for HCV, 29.2% of whom tested positive. 34.8% of HCV-positive patients were tested for HIV, 4.9% of whom tested positive. Of those tested, HCV-positive patients were significantly more likely than HCV-negative patients to test positive for HIV; HIV-positive patients were no more likely to test positive for HCV than HIV-negative patients. HIV-positive patients with substance use disorders (SUD) were significantly more likely to test HCV positive than those without. Within the total sample, veterans with SUD were significantly more likely to be tested for both diseases and to test positive for HCV but not HIV. After controlling for other categories of SUD, veterans with a history of cocaine abuse compared with those without were at an increased risk of HIV infection and co-infection. CONCLUSION:: 79.1% of HIV-positive but only 34.8% of HCV-positive veterans were co-tested, suggesting barriers to HIV testing may exist in VISN 20. Results also indicate that HCV-positive patients are at increased risk for HIV infection and that HIV-positive patients with SUD are at increased risk of HCV infection; routine co-testing for these patients is therefore warranted. Given significant co-infection rates, HCV and HIV screening and testing should be increasingly integrated. Increased infection rates among patients with SUD also warrant integration of HCV and HIV screening and testing into mental health and addiction programmes.


  • James L. Sorensen,  and Amy L. Copeland, 2000. Drug abuse treatment as an HIV prevention strategy: a review.  Drug and Alcohol Dependence, Volume 59, Issue 1 , 1 April 2000, Pages 17-31.


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


  • J. A. Baldwin, R. T. Trotter, D. Martinez, et al. (1999) HIV/AIDS risks among Native American drug users: key findings from focus group interviews and implications for intervention strategies. AIDS Education and Prevention , Volume (Issue):  11(4) pp. 279-292.


A multisite study funded through the National Institute on Drug Abuse and the Office of Research on Minority Health was conducted in 1996 to determine the HIV/AIDS prevention programming, one component of this study entailed conducting a series of focus groups at each of four sites: Anchorage, Alaska; Denver, Colorado; Flagstaff, Arizona; and Tucson, Arizona. While some site differences were noted, several consistent thematic findings were revealed across all locations. Specifically, focus group members strongly recommend directly involving key members of the Native American community in conducting outreach and intervention activities, involving native people as the sources of information, and utilising local and tribally relevant forms of delivering the message. Other consistent themes included getting messages to smaller communities to prevent the potential "annihilation' of tribes, educationg youth, and linking alcohol prevention education to HIV/AIDS education. Findings from this study support the idea that future HIV/AIDS prevention programs must take into account subgroup and individual level differences among Native American drug users. 


  • J. L. Sorensen, A. Mascovich, T. L. Wall, et al. (1998) Medication adherence strategies for drug abusers with HIV/AIDS. AIDS Care . Volume (Issue):  10(3) pp. 297-312.


This paper describes two clinical techniques aiming to improve adherence to medications for HIV/AIDS in methadone maintenance patients. The first technique, providing on-site dispensing of antiretroviral medications, enhanced medication adherence but did not produce enduring effects beyond the time of the intervention. To develop a more long-lasting intervention, the programme is experimenting with more individualised medication management, in which a staff member provides assessment and problem solving to help improve medication adherence. Clinical and practical issues are presented - including each technique's aims, screening and recruitment of participants, description of the technique, staff and administrative support issues and research results. The paper aims to assist staff in drug treatment programmes to implement interventions that can increase adherence to medications for HIV/AIDS.


  • Katerina Barcal, Joseph E Schumacher, Kostyantyn Dumchev et al. (2004) A situational picture of HIV/AIDS and injection drug use in Vinnitsya, Ukraine. CMAJ,  March 1, 2005; 172 (5).


Background. New and explosive HIV epidemics are being witnessed in certain countries of Eastern Europe, including Ukraine, as well as a rapid and dramatic increase in the supply, use, and negative public health consequences of illicit drugs. A majority of registered HIV cases in Ukraine occur among injection drug users (IDUs), large numbers of whom report HIV risk behaviors such as needle sharing. The purpose of this study was to apply the World Health Organization's Rapid Assessment and Response on Injection Drug Use (IDU-RAR) guide to create a situational picture in the Vinnitsya Oblast, Ukraine, a region with very scarce information about the HIV/AIDS and injection drug use (IDU) epidemics.


The IDU-RAR uses a combination of qualitative data collection techniques commonly employed in social science and evaluation research to quickly depict the extent and nature of the given health problem and propose locally relevant recommendations for improvement. The investigators focused their assessment on the contextual factors, drug use, and intervention and policy components of the IDU-RAR. A combination of network and block sampling techniques was used. Data collection methods included direct observation, review of existing data, structured and unstructured interviews, and focus group discussions. Key informants and locations were visited until no new information was being generated.


The number of registered HIV cases in Vinnitsya has increased from 3 (1987-1995) to 860 (1999-10/2004), 57 of whom have already died. Ten percent of annual admissions to the area's Regional Narcological Dispensary were for opiate disorders, and the number of registered IDUs rose by 20% from 1999 to 2000. The level of HIV/AIDS awareness is generally poor among the general population but high among high-risk populations. Both HIV/AIDS and injection drug use carry a strong stigma in the community, even among medical professionals. There was very little evidence of primary HIV/AIDS prevention efforts, and IDU prevention efforts focused on promotion of anti-drug messages in the schools.


Given that Ukraine has sparse resources to be devoted to this problem, action recommendations should be prioritized, realistic, and initially targeted to persons in greatest need. The following action recommendations are prioritized by the following categories: First priority: Voluntary Counseling and Testing; Second Priority: Prevention and Education; and Third Priority: Harm Reduction and Treatment. They are provided in this sequence based on what response can realistically be implemented first with limited additional resources and can make the greatest immediate impact. The persons at greatest risk, HIV positive persons and IDUs, should be attended to first.


  • K. M. Broome, G. W. Joe & D. D. Simpson,(1999). HIV risk reduction in outpatient drug abuse treatment: individual and geographic differences. AIDS Education and Prevention . Volume (Issue):  11(4) pp. 293-306.


In the national Drug Abuse Treatment Outcome Studies (DATOS), many clients in outpatient methadone treatment (OMT) and outpatient drug-free (ODF) modalities were admitted with multiple sex and needle risk behaviours, but they reduced these risks significantly during treatment. Using hierarchical linear model regression analysis, the authors examined client and treatment program characteristics as predictors of initial risk levels and of reductions over time. Clients who used cocaine frequently before treatment or had antisocial personality disorder entered treatment with elevated risks. In both modalities, cocaine users reduced risky behaviours significantly, but antisocial clients did so only in OMT. Treatment programs located in cities with higher prevalence rates of HIV/AIDS admitted clients with lower baseline levels of risk behaviour than found in other cities. OMT programs in lower prevalence cities achieved higher rates of risk reduction than programs in higher prevalence cities. Reduction of sex and needle risk in both OMT and ODE modalities indicates the importance of outpatient drug abuse treatment to national HIV prevention policy. 


  • K. I. Stajdhuhar, L. Poffenroth, E. Wong, et al. (2004) Missed opportunities: injection drug use and HIV/AIDS in Victoria, Canada.  International Journal of Drug Policy . Volume (Issue):  15(3) pp. 171-181.


This paper reports qualitative findings from a study examining the context of injection drug use (IDU) and HIV/AIDS in Victoria, Canada. Objectives were to determine behaviours and situations that place IDUs at risk for blood-borne diseases and to use this information to develop interventions to mitigate harms associated with IDU. Rapid Assessment Response and Evaluation (RARE) methodology was used. Data were collected by: (1) key informant and focus group interviews; (2) participant observation in drug "hot spot" areas; (3) geo-mapping; (4) rapid assessment surveys; and (5) a questionnaire. Findings suggest drug use practices placed IDUs at risk for a number of health problems and even though IDUs were aware of risks and engaged in protective behaviours, almost all said their lives were ruled by the intense need for drugs. Risk behaviours were linked to mis-conceptions about drug use and addiction, social settings, lack of access to health services, societal attitudes and stigmatisation, and by philosophical differences that existed among service organisations. Findings have been instructive in setting policy and laying the foundation for an action plan to address the health needs of those with addictions in Victoria.


  • Knight KR; Purcell D; Dawson-Rose C; Halkitis PN; Gomez CA (2005) Sexual risk taking among HIV-positive injection drug users: contexts, characteristics, and implications for prevention. AIDS Education and Prevention. 2005;17 Suppl A:76-88.


HIV-positive injection drug users (IDUs) (N = 161) were recruited to complete a qualitative interview and a quantitative survey about sexual behavior and transmission risk. We identified two contexts in which exposure encounters occurred most commonly for HIV-positive IDUs: in intimate serodiscordant relationships and in the drug/sex economy. Salient characteristics in both contexts included the role of intimacy, drug use and sexual decision making, disclosure of HIV status, and perceived responsibility. Although these characteristics emerged in both risk contexts, they operated differently within each context. The preservation of intimacy was paramount among those in serodiscordant relationships, and agreements to take risks were common. In the drug/sex economy, serostatus disclosure was uncommon and drug acquisition and use played a significant role in sexual risk taking. Our data emphasize a need to address the specific transmission risk contexts occurring among HIV-positive IDUs and to prioritize social and interpersonal factors when promoting safer sexual norms among HIV-positive IDUs.


  • L. O. Gostin, Z. Lazzarini, T. S. Jones & K. Flaherty, 1997. Prevention of HIV/AIDS and other blood-borne diseases among injection drug users. JAMA: Journal of the American Medical Association. Volume (Issue):  277(1) pp. 53-62.


The authors report the results of a survey of laws and regulations governing the sale and possession of needles and syringes in the USA and its territories and discuss legal and public health proposals to increase the availability of sterile syringes, as a human immunodeficiency virus (HIV) transmission prevention measure, for persons who continue to inject drugs. Every state, the District of Columbia (DC), and the Virgin Islands (VI) have enacted state or local laws or regulations that restrict the sale, distribution, or possession of syringes. Drug paraphernalia laws prohibiting the sale, distribution, and/or possession of syringes known to be used to introduce illicit drugs into the body exist in 47 states, DC, and VI. Syringe prescription laws prohibiting the sale, distribution, and possession of syringes without a valid medical prescription exist in eight states and VI. Pharmacy regulations or practice guidelines restrict access to syringes in 23 states. The authors discuss the following legal and public health approaches to improve the availability of sterile syringes to prevent blood-borne disease among injection drug users: (1) clarify the legitimate medical purpose of sterile syringes for the prevention of HIV and other blood-borne infections; (2) modify drug paraphernalia laws to exclude syringes; (3) repeal syringe prescription laws; (4) repeal pharmacy regulations and practice guidelines restricting the sale of sterile syringes; (5) promote professional training of pharmacists, other health professionals, and law enforcement officers about the prevention of blood-borne infections; (6) permit local discretion in establishing syringe exchange programmes; and (7) design community programmes for safe syringe disposal. 


  • L. Sagliocca, G. Rezza, D. Vlahov, et al. (1997) A morphine prescription program in Italy (1980-1985): retrospective evidence of protection against HIV/AIDS . Addiction Research.  Volume (Issue):  5(2) pp. 137-144.


The purpose of this study was to determine if morphine programmes implemented in the city of Naples (Italy) between 1980 and 1985 might have contributed to the low HIV prevalence rate detected among injecting drug users (IDUs). A case-control study was conducted, comparing 69 HIV-positive and 266 HIV-negative IDU's attending a large drug treatment centre in Naples in the period 1980-1984. Cases were less likely than HIV-negative controls to have been prescribed morphine, though the difference was only marginally significant (odds ratio = 0.57; 0.20-1.35). The results suggest that HIV infection tended to be less common among those prescribed morphine. These findings are somewhat unexpected considering that the alternative treatment was represented by methadone provided orally. However, methadone was often given at low, insufficient doses, and was associated with persistent unsafe drug injection. Persons prescribed morphine were able to visit pharmacies every day where they were also able to purchase sterile injection equipment. The suspension of the morphine programmes should be re-evaluated on the basis of these new results. 


  • Marcotte, David; Avants, S Kelly; Margolin, Arthur (2003) Spiritual self-schema therapy, drug abuse, and HIV. Journal Of Psychoactive Drugs,  Volume 35, Issue 3 , July - September 2003, Pages 389-391.


This case report describes the use of Spiritual Self-Schema (3-S) therapy in the treatment of an HIV-positive inner-city drug user maintained on methadone and referred for additional treatment due to unremitting cocaine use. 3-S therapy is a manual-guided intervention based on cognitive self-schema theory. Its goal is to help the patient create, elaborate, and make accessible a cognitive schema--the "spiritual" self-schema-that is incompatible with drug use and other HIV risk behaviors. 3-S therapy facilitates a cognitive shift from the habitual activation of the "addict" self-schema, with its drug-related cognitions, scripts and action plans, to the "spiritual" self-schema, with its associated repertoire of harm reduction beliefs and behaviours.


  • M. Beardsley, M. F. Goldstein, S. Deren & S. Tortu, (1996). Assessing intervention efficacy: an example based on change profiles of unprotected sex among drug users. Journal of Drug Issues, Volume (Issue):  26(3) pp. 635-648.


Over 700 active drug users recruited in East Harlem, New York City, to participate in an AIDS prevention project were interviewed on two occasions, six months apart, to assess changes in HIV-related risk behaviours. This paper presents an example of a method for analysing patterns of risk behaviour change over time as a means of comparing the effectiveness of two interventions. Results described in this paper focus on the number of unprotected sex acts reported in the 30 days prior to each interview and reflect five distinct patterns of risk level over time (i.e. a decrease, an increase, remaining at low risk, remaining at high risk or no sexual activity at either time). Bivariate and multivariate analyses indicated that: (1) compared to persons at high levels of unprotected sex at follow-up (time 2), those who remained at a low level or decreased were more likely to be HIV positive; and (2) age, living alone and having a stable source of income were also significant predictors of risk pattern. Risk pattern was not associated with type of risk reduction intervention (standard or enhanced) or with drug treatment (yes or no) between baseline and follow-up. Implications of the findings were discussed with respect to: (1) the assessment of efficacy of AIDS prevention interventions; and (2) the analysis of risk behaviour changes over time.


  • Memoona Hasnain (2004) Cultural Approach to HIV/AIDS Harm Reduction in Muslim Countries. Harm Reduction Journal: 2: 23.


Muslim countries, previously considered protected from HIV/AIDS due to religious and cultural norms, are facing a rapidly rising threat. Despite the evidence of an advancing epidemic, the usual response from the policy makers in Muslim countries, for protection against HIV infection, is a major focus on propagating abstention from illicit drug and sexual practices. Sexuality, considered a private matter, is a taboo topic for discussion. Harm reduction, a pragmatic approach for HIV prevention, is underutilized. The social stigma attached to HIV/AIDS, that exists in all societies is much more pronounced in Muslim cultures. This stigma prevents those at risk from coming forward for appropriate counseling, testing, and treatment, as it involves disclosure of risky practices. The purpose of this paper is to define the extent of the HIV/AIDS problem in Muslim countries, outline the major challenges to HIV/AIDS prevention and treatment, and discuss the concept of harm reduction, with a cultural approach, as a strategy to prevent further spread of the disease. Recommendations include integrating HIV prevention and treatment strategies within existing social, cultural and religious frameworks, working with religious leaders as key collaborators, and provision of appropriate healthcare resources and infrastructure for successful HIV prevention and treatment programs in Muslim countries.


  • Mehta SH, Thomas DL, Sulkowski et al. (2005) A framework for understanding factors that affect access and utilization of treatment for hepatitis C virus infection among HCV-mono-infected and HIV/HCV-co-infected injection drug users. AIDS, Oct;19 Suppl 3:S179-S189.


Treatment for hepatitis C virus (HCV) is rarely received by injection drug users (IDU), particularly those co-infected with HIV. We propose a framework for understanding factors that affect utilization and adherence to HCV therapy among HCV mono-infected and HIV/HCV-co-infected IDU. Provision of treatment requires calculation of risks and benefits including evaluation of a number of time-varying factors that collectively determine a gradient of treatment eligibility, advisability and acceptability, the relative importance of which may differ in co-infected and mono-infected IDU. Treatment eligibility is determined by a number of non-modifiable and modifiable contraindications, the latter of which can change over time rendering patients who were once ineligible eligible. Among those eligible, treatment need can be assessed by liver biopsy and therapy may be deferred in those with no liver disease and started in those with significant liver disease. Among those with moderate disease, further consideration of treatment advisability (medical factors that affect treatment response) and acceptability (individual, provider and environmental barriers) is needed before treatment decisions are made. These factors are dynamic and thus should be continually evaluated even among those who may not initially appear to be ready for treatment. An evaluation of this framework is needed to determine applicability and feasibility. Until then, treatment decisions should be made on an individual basis after careful consideration of these issues by provider and patient and efforts to develop novel strategies for identifying IDU who need treatment most (alternatives to liver biopsy) and multidimensional approaches to deliver treatment for HCV while addressing other factors including HIV infection, depression and drug use should be continued.


  • M J Tong and N S el-Farra (2005) Clinical sequelae of hepatitis C acquired from injection drug use. Harm Reduct Journal, 2: 16.


We determined the course of hepatitis C infection in 125 patients with a history of injection drug use. The mean age at presentation was 43.5 years, and the mean age of initiating injection drug use was 23.1 years. Fatigue and hepatomegaly were present in as many as 60% of patients. All had antibodies to the hepatitis C recombinant protein C25, and 99% were positive for hepatitis C virus RNA. After the initial workup, 33 (26%) patients had chronic hepatitis, 46 (37%) had chronic active hepatitis, 45 (36%) had cirrhosis, and 1 (0.8%) presented hepatocellular carcinoma. During follow-up, hepatocellular carcinoma developed in 2 other patients. In 74 patients with a 1-year history of injection drug use, the mean number of years to the development of chronic hepatitis, chronic active hepatitis, cirrhosis, and hepatocellular carcinoma were 15.6, 17.6, 19.4, and 26.3 years, respectively. In this subgroup of patients, heavy alcohol abuse did not appear to influence the progression of liver disease. The 2-year case-fatality rate was 2%. Our findings indicate that hepatitis C is a progressive disease, but only a few died during the average 20.4 years after the initiation of injection drug use. Antiviral treatment to eradicate the virus and halt the progression of disease is indicated in this group of patients.


  • M. L. Williams, R. C. Freeman, A. M. Bowen & L. Saunders (1998) The acceptability of a computer HIV/AIDS risk assessment to not-in-treatment drug users. AIDS Care . Volume (Issue):  10(6) pp. 701-711.


The purpose of this paper is to report the results of a study assessing the acceptability of a computer HIV risk assessment instrument administered to not-in-treatment drug users. The study asked three questions related to acceptability: (1) are drug users comfortable responding to HIV risk questions using the computer assessment; (2) do drug users feel that they possess the requisite skill to respond to questions using a computer; and (3) do drug users believe that the responses they provide using the computer assessment will remain private and confidential. This study differs from other assessments of the acceptability of computer assisted data collection in that the population of interest has only limited education and interaction with computers. Furthermore, the study was implemented under field conditions. To conduct the study, an existing HIV risk assessment instrument was adapted for use with the computer. Only slight modifications were made to the content of the instrument. To facilitate data collection with this population, audio enhancement and touch screen were used. Three scales measuring comfort, skill and perceived privacy were developed. Results of analysis showed that drug users are comfortable responding to an HIV risk assessment using computer assisted interviewing. Drug users also perceived that they possessed the requisite skill to successfully complete the interview. And, study participants reported that they believed that their responses using the computer interview would remain private and confidential. Only minor differences in scale scores based on sociodemographic characteristics were found among study participants. Implications of the findings are discussed. 


  • Mc Mahon RC, Malow RM, Jennings TE, Gomez CJ. (2001) Effects of a cognitive-behavioral HIV prevention intervention among HIV negative male substance abusers in VA residential treatment. AIDS Educ Prev . 2001 Feb;13(1):91-107.


This investigation compared the effectiveness of a cognitive-behavioral HIV risk reduction intervention with a standard care (SC) comparison condition in modifying HIV risk related knowledge, beliefs, attitudes, and behaviour at 6-month and 12-month follow-ups among 149 HIV sero-negative males. The two intervention conditions were administered while participants were in inpatient alcohol and other drug abuse treatment. Global drug abuse severity, as well as injection drug abuse, decreased significantly from pre--intervention to follow-up across conditions. There were significant increases in the proportions reporting sexual activity and increases in levels of unprotected sex acts between baseline and follow-up across conditions. However, no changes in sex risk behaviour were found among those who reported sexual activity both prior to and after intervention across conditions. Participants revealed relatively adequate knowledge regarding HIV and HIV risk reduction practices, strong belief in the utility of safer practices and in their ability to enact such practices, and relatively strong commitment to practice safer sex across conditions at baseline assessment. In general, substantial post intervention improvements over baseline levels in these areas were not found. Relatively modest changes in sexual self-efficacy and in safe-sex guidelines were identified in analyses involving the total sample. Exploratory subgroup analysis suggested increases in knowledge and reductions in susceptibility and anxiety among those who reported sexual activity both prior to and after intervention. Among participants reporting initiation of sexual activity after intervention, those receiving SC revealed changes in perceived susceptibility and in condom attitudes. A discussion is presented of challenges associated with providing meaningful HIV risk reduction intervention when baseline levels of sex risk behaviour, perceived HIV infection susceptibility, and HIV anxiety are only moderate and when initial levels of sexual self-efficacy and commitment are relatively high.


  • Nyamathi, Adeline M, Christiani Ashley, Windokun Folasade, et al. (2005) Hepatitis C virus infection, substance use and mental illness among homeless youth: a review. AIDS . 19 Suppl 3:S34-S40, October.


Objectives: Homeless youth are at a high risk of substance abuse, mental illness and blood-borne infections, such as hepatitis C. In this paper, we review the implications of these conditions, discuss the unique challenges faced by homeless youth, and explore potential strategies for harm reduction and intervention in this vulnerable population. Results: Interventions that combine youth-centered, service-based care, street outreach, case management, and motivational interviewing with integrated health services such as hepatitis A/B vaccination, and mental health and substance abuse programmes, are presented as innovative approaches to address the healthcare needs of homeless youth. Conclusion: Recommendations for age-appropriate interventions and further research are made.


  • Peter A. Selwyn, 1996. The impact of HIV infection on medical services in drug abuse treatment programs. Journal of Substance Abuse Treatment . Volume 13, Issue 5 , September-October 1996, Pages 397-410


The HIV/AIDS epidemic has had a profound impact on the organization and delivery of clinical services in drug abuse treatment programs. The need for emphasis on HIV prevention vs. treatment services has varied with the geographic distribution of HIV infection among drug injectors. On-site primary medical care services have been developed in some treatment programs, whereas other programs have had to formalize arrangements for referral or contractual care with outside medical providers. No single model of care is necessarily appropriate for all drug treatment programs, and, along with the potential benefit, each may pose structural challenges that need to be addressed. The advent of the AIDS epidemic may have served, in an inadvertently positive way, to draw attention to the increasingly illogical separation between drug abuse treatment and the larger medical care system. This review will examine the epidemiologic, clinical, organizational, and policy issues generated by the increased medical needs of drug users with HIV infection in treatment program settings.


  • R. Braithwaite, T. Stephens, R. C. Conerly, et al. (2004). The relationship among marijuana use, prior incarceration, and inmates' self-reported HIV/AIDS risk behaviours. Addictive Behaviors . Volume (Issue):  29(5) pp. 995-999.


Inmates report use of a wide range of drugs including heroin, methadone, and cocaine at some point in their lives without a doctor's prescription. The most commonly used drugs include marijuana and cocaine; tobacco and alcohol are also widely used. The present study explores the relationship between marijuana use and prior incarceration on 208 inmates' self-reported HIV/AIDS risk behaviours. Analysis involved descriptive and chi-square tests of association. Findings indicate that inmates with higher self-reported levels of education were significantly less likely than others to be repeat offenders. Data also support the argument that income prior to the most recent arrest and frequency of marijuana use was related to the outcome of being a repeat offender. 


  • R. C. Freeman, M. L. Williams & L. A. Saunders (1999)  Drug use, AIDS knowledge, and HIV risk behaviors of Cuban-, Mexican-, and Puerto-Rican-born drug injectors who are recent entrants into the United States. Substance Use and Misuse . Volume (Issue):  34(13) pp. 1765-1793. 


To date, relatively little research attention has been devoted to the HIV-risky behaviours of persons who are newly arrived in the United States and who use drugs. Data gathered from street-recruited injection drug users (IDUs) recruited in ten United States cities who were born in Mexico, Cuba, and Puerto Rico and who are recent entrants into the United States suggest that, in comparison to US-born IDUs, Mexcian-born subjects are at elevated risk for acquiring and transmitting HIV as a result of sharing needles with friends and running partners; sharing drug injection implements such as cookers, cotton, and rinse water; frequent injection in HIV-risky settings; use of unsterilised needles; and relatively frequent trading of sex for drugs or money. Puerto-Rican-born IDUs were found to inject drugs relatively frequently, and to do so relatively often in high-risk settings in which sterile injecting equipment and cleaning materials often are scarce. These data also show generally lower levels of AIDS knowledge among the immigrant IDUs than among US-born IDUs. Respondents from each nationality group most often cited television as the source of their most useful and reliable HIV information, but also tended to regard community outreach workers as a significant source of reliable AIDS and needle cleaning information. The high levels of involvement in HIV-risky behaviours, deficits in knowledge concerning the means of HIV transmission, and relative ease of mobility of the at-risk (for HIV) individuals examined here indicate a need for a comprehensive public health prevention initiative to limit the future spread of HIV. At a minimum, such an undertaking would do well to incorporate group-specific, culturally appropriate behavioural interventions as well as an information campaign. 


  • Robert S. Remis (2000) HIV incidence among injection drug users in VancouverJAMC: 7 MARS 2000; 162 (5).

In this issue (page 894), Patricia Spittal and colleagues report that HIV incidence among injection drug users (IDUs) in Vancouver's Downtown Eastside appears to be greater among women than among men.1 As the authors point out, this is an unusual finding and grounds for concern. Although not emphasized in the report, HIV infection rates were substantially higher, about twice as high, among both male and female Aboriginal IDUs compared with non-Aboriginals. As a substantially higher proportion of women in the study self-reported identification as an Aboriginal, 41.0% compared with 16.5% for the men, much of the observed difference was probably related to Aboriginal status. In fact, the cumulative HIV incidence rate among Aboriginal subjects was 19.0% (19.4% for women and 18.4% for men) compared with 9.3% among non-Aboriginal subjects (11.3% in women and 8.6% for men). Thus, a very important interpretation of their study is that HIV rates were higher among Aboriginal IDUs.

Aside from the issue of Aboriginal status, women appear to have been at somewhat increased risk of HIV seroconversion. This may have been related to sexual exposure to HIV infection; in fact, both unsafe sex with a regular partner and having an HIV-positive partner were independently associated with infection among women, but not among men. In other studies, women have been found to be at higher risk of infection from sex than men2 for biologic and perhaps other reasons. This should be a significant part of both the interpretation of the results and consideration of the public health implications.

Beyond the finding of the high HIV incidence observed among women, which is related mostly to a high rate among Aboriginals, the most important finding of the study is the continuing high rates of transmission of HIV among IDUs in Vancouver. Based on estimates from the Kaplan-Meier analysis presented in the paper, annual HIV infection rates were in the range of 3%-5%. For some reason, the rates were substantially higher in the first 6 months following recruitment into the study (12%-18% annual rate) compared with later on (about 2%-3%); it is unclear whether this is a cohort or a calendar effect. Nevertheless, even an incidence of 2% is exceedingly high; HIV infection is still serious and potentially fatal and only in part mitigated by effective antiretroviral regimens. Furthermore, use of these regimens among injection drug-using populations who continue to inject presents major challenges with respect to adherence: studies have shown that adherence must be exceptionally high (>> 95%) for such regimens to be effective.3 Thus, this high rate of HIV transmission reflects a catastrophic situation that, if sustained, will cause thousands of IDUs in Vancouver alone to acquire this infection over the next decade, with untold cost in expenses for medical and other support services as well as in human misery. Despite the fact that Vancouver has one of the highest volumes of needle exchange in Canada and the world, HIV transmission continues to occur at an alarming rate.

The observations from this and other similar studies must cause us to reassess our current strategy for controlling HIV infection. First, we must reconsider the legal framework of society's response to substance abuse, in general, and injection drug use, in particular. Clearly, the expensive and resource-draining activities devoted to the enforcement of Canada's drug laws must be seriously questioned. This is the current preoccupation of the House of Commons Special Committee on the Non-Medical Use of Drugs, which is currently in the process of gathering information through national hearings. We will need to be particularly wise and open-minded about considering different and potentially more effective modifications to our drug laws and their enforcement. It is probably opportune to consider decriminalizating simple possession and treating substance abuse primarily as a medical and public health problem rather than a criminal one. Society should hesitate to put such efforts into censuring behaviour that, in a direct sense, has no other victim than the person himself or herself.

The development and implementation of "safe injection sites" is an intriguing option that may be of some benefit to a subset of the IDU population.4 The efficacy, effectiveness and efficiency of such an approach remain, however, to be demonstrated. It may be that the people who need such facilities most are in a chaotic and disorganized state and are not likely to use them. Nevertheless, I believe that safe injection sites are a worthwhile option that deserves to have a systematic and rigorous evaluation.

The accessibility of services at all thresholds must also be seriously reassessed. Needle exchanges should do far more than provide needles; they should be the port of entry into a care system that can help many, though not all, in a vulnerable population to deal effectively with their addiction. In many parts of the country, waiting lists for detoxification programs are long and deter individuals who are ready to deal with their addiction from doing so. Obstacles to individuals' access to detoxification and rehabilitation must be removed

Finally, we must seriously re-examine our social policy, especially in the context of the Aboriginal population. Current policies create the conditions for social degeneration and disorganization that lead to multiple psychological and social problems, including injection drug use. We must fully involve addicted individuals in efforts to identify new and potentially effective means to address the problem of addiction, as well as to increase the proportion of injections that are free from the risk of HIV and other serious bloodborne infections.

Unfortunately, it is difficult to be hopeful in this regard. Similar observations were made in a study from the same group almost exactly 5 years ago,5 following the first wave of high HIV incidence among IDUs in Vancouver. One has to wonder what it will take for policy-makers to deal seriously with this problem.


  • Ross Dana; Schumacher Joseph E ( 2004) Condom use assessment of persons in drug abuse treatment. Journal Of Community Health, Volume 29, Issue 6 , December 2004, Pages 499-509


The purpose of this study was to objectively and quantitatively assess individual skill level of male condom use. This study developed a reliable and face valid assessment of correct male condom use based on Centers for Disease Control and Prevention criteria. Participants (N= 163) were recruited from persons in treatment for cocaine addiction. Condom use was assessed on the basis of correct completion of eight discrete steps. An overall score of 40% correct condom use indicated the need for training in this sample. Assessment showed training needs especially related to steps involving reduction of ejaculate leakage and steps related to potential hazards of nonoxynol-9 use. Frequency of condom use was also assessed; there was no correlation between frequency of condom use and condom use skill. Drug addiction treatment programs are encouraged to incorporate HIV risk reduction programs that teach condom use skills and use the CUDOS as an empirical measure of condom skill acquisition.


  • R. K. Hopson, J. A. Peterson & K. J. Lucas (2001) Tales from the 'hood': framing HIV/AIDS prevention through intervention ethnography in the inner city. Addiction Research & Theory . Volume (Issue):  9(4) pp. 339-363.


The purpose of the research reported here was to contribute to the understanding of the social context of AIDS in the inner city through the use of ethnography in public health intervention. The authors adopted an HIV/AIDS team ethnographic intervention approach to HIV prevention in lower status communities in Baltimore City, Maryland, involving the documentation of observations, experiences, and narratives of study participants. These 'tales from the hood' build a picture of the social world of the drug-addicted and diseased in the inner city as a basis for the design of appropriate HIV/AIDS intervention and drugs research. This paper is divided into several sections. The first section highlights the role of ethnography in drugs and disease research in the United States, with particular attention to some of the more celebrated actities that have occurred in the last 20 to 30 years. The second section outlines the rationale and methods employed in the ethnographic intervention study, and the third section provides a description of findings that were documented during the ethnographic process.


  • R. M. Cunningham-Williams, L. B. Cottler, W. M. Compton, et al. (1999) Reaching and enrolling drug users for HIV prevention: a multi-site analysis. Drug and Alcohol Dependence . Volume (Issue):  54(1) pp. 1-10.


Since 1994, several sites have participated in a NIDA Cooperative Agreement for AIDS Community-based Outreach/Intervention Research Program to examine rates of HIV risk behaviours and evaluate HIV risk reduction interventions among out-of-treatment drug injection and crack cocaine and heroin smokers. The authors studied the process and outcome of community outreach for recruitment of drug users in AIDS research and education projects in three metropolitan areas: St Louis, Missouri, San Antonio, Texas and Durham and Wake Counties, North Carolina. There were two primary areas of focus: (1) the level of accuracy among community health outreach workers (CHOWs) in identifying potentially eligible persons for HIV prevention; and (2) overall effectiveness in recruiting and enrolling persons in formal assessment and intervention studies. The authors found cross-site and within-site differences in levels of accuracy and in recruitment and enrolment yields. Drug users who had never been in treatment and drug users who had never been tested for HIV infection were underrepresented at all sites. They discuss the factors which may have contributed to cross-site and within-site differences. The findings suggest a need for continued study, refinement and evaluation of community outreach strategies in order to enrol a broad spectrum of vulnerable groups in HIV prevention activities. 


  • Sharon Stancliff, Bruce Agins, Josiah D Rich, and Scott Burris (2003) Syringe access for the prevention of blood borne infections among injection drug users . CMAJ, April 2, 2002; 166 (7)


Background: Approximately one-third of acquired immunodeficiency syndrome cases in the United States are associated with the practice of sharing of injection equipment and are preventable through the once-only use of syringes, needles and other injection equipment. Discussion:Sterile syringes may be obtained legally by 4 methods depending on the state. They may be purchased over the counter, prescribed, obtained at syringe exchange programs or furnished by authorized agencies. Each of these avenues has advantages and disadvantages; therefore, legal access through all means is the most likely way to promote the use of sterile syringes. Summary:By assisting illicit drug injectors to obtain sterile syringes the primary care provider is able to reduce the incidence of blood borne infections, and educate patients about safe syringe disposal. The provider is also able to initiate discussion about drug use in a non judgmental manner and to offer care to patients who are not yet ready to consider drug treatment.


  • S. Davidson, F. Judd, D. Jolley, B. Hocking, et al. (2001) Risk factors for HIV/AIDS and hepatitis C among the chronic mentally ill. Australian and New Zealand Journal of Psychiatry. Volume (Issue):  35(2) pp. 203-209.


The objective of this study was to document the prevalence of risk factors for HIV/AIDS and hepatitis C among people with chronic mental illness treated in a community setting. Two hundred and thirty four patients attending four community mental health clinics in the North-western Health Care Network in Melbourne, Australia, completed an interviewer-administered questionnaire which covered demographics, risk behaviour and psychiatric diagnosis. The sample was 58% male, and 79% of the sample had a primary diagnosis of schizophrenia. Forty-three percent of mentally ill men and 51% of mentally ill women in the survey had been sexually active in the 12 months preceding the survey. One-fifth of mentally ill men and 57% of mentally ill women who had sex with casual partners never used condoms. People with mental illness were eight times more likely than the general population to have ever injected illicit drugs and the mentally ill had a lifetime prevalence of sharing needles of 7.4%. The prevalence of risk behaviours among the study group indicate that people with chronic mental illness should be regarded as a high-risk group for HIV/AIDS and hepatitis C. It is essential that adequate resources and strategies are targeted to the mentally ill as they are for other high-risk groups.


  • S. Ferrando, K. Goggin, M. Sewell, et al. (1998)  Substance use disorders in gay/bisexual men with HIV and AIDS. American Journal on Addictions . Volume (Issue):  7(1) pp. 51-60.


The authors conducted a longitudinal study of psychological adaptation to AIDS in subjects with and without lifetime and current substance use disorders (SUD), in a cohort of HIV+ gay/bisexual subjects. A sample of HIV+ gay/bisexual men (n = 183) and an HIV- comparison group (n = 84) were assessed for SUD, depression and anxiety disorders. Among HIV+ men, combined lifetime (42 percent) but not current (11.5 percent) SUDs were more prevalent than in HIV- men (27 percent and 10 percent, respectively). HIV+ men with current SUD reported more depression, distress and diminished quality of life than HIV+ men with no SUD, but HIV-illness severity did not differ. HIV+ men in recovery did not differ from men with no lifetime history. Most HIV+ gay/bisexual men with SUD discontinue or reduce substance use before or subsequent to knowledge of their HIV infection, probably in an attempt to adopt a healthier lifestyle. However, for some HIV+ men, persistent substance abuse/dependence is accompanied by higher levels of distress and diminished quality of life, underscoring their need for treatment intervention. 


  • S. J. Boyd, N. F. Thomas-Gosain, A. Umbricht, et al. (2004) Gender differences in indices of opioid dependency and medical comorbidity in a population of hospitalized HIV-infected African-Americans. American Journal on Addictions . Volume (Issue):  13(3) pp. 281-291.


The authors examined gender differences in drug use patterns and in medical presentation among 520 hospitalised, HIV-infected African-Americans. Substance abuse history was self-reported, and medical data were obtained by chart review. Overall, 321 (65%) reported ever having used heroin, with equivalent rates in men and women. Women were more likely to report current use, to have sought treatment, and tended to feel more dependent on heroin than men. Among heroin users, women were more likely to be admitted for conditions related to drug use, rather than AIDS, and to have CD4 counts > 200 / mm310. These gender differences in opioid dependency and medical comorbidity may indicate a need for alternative treatment approaches for men and women. 


  • S. S. Martin, D. J. O'Connell, J. A. Inciardi, et al. (2003). HIV/AIDS among probationers: an assessment of risk and results from a brief intervention. Journal of Psychoactive Drugs . Volume (Issue):  35(4) pp. 435-443.


A number of studies have examined HIV risk behaviours in prisoner populations, but relatively few have examined such behaviours in probationer populations. Since probationers have more opportunities to engage in risk behaviours than do prisoners, the potential importance of HIV interventions with probationers becomes readily apparent. This article examines a sample representative of the supervised probationer population in Delaware. The sample respondents received a baseline interview, then were randomly selected to receive either an enhanced version of NIDA standard HIV Intervention or a Focused Intervention based on a cognitive thought-mapping model. Intervention boosters were offered at two follow-up intervals in the following three months, and respondents were re-interviewed at six months. The data at baseline suggest that probationers in Delaware have levels of injection drug use, other serious drug use and rates of risky sexual behaviours that approach those observed in prison populations. The interventions' effectiveness in changing attitudes and behaviours at the six-month interview was then examined. The data support the conclusion that brief interventions can significantly impact both drug use and sexual risk behaviours among probationers. However, there do not appear to be significant improvements for those receiving the more intensive Focused Intervention, as compared to those who receive the enhanced Standard Intervention. Further work will consider what components in programmes and characteristics in clients should be considered in selecting the most appropriate interventions for probationers. 


  • Swanson, J; Cooper, A (1998) The role of alcohol and drug relapse prevention in the treatment and prevention of HIV disease. Journal Of The International Association Of Physicians In AIDS Care, Volume 4, Issue 4 , April 1998, Pages 14-19


Alcohol and drug relapse prevention may help HIV-positive patients to comply with their complex treatment regimens. In the atmosphere of increasing concern about HIV treatment compliance, the goal of relapse prevention is for individuals to become aware of their own high-risk situations and learn effective life-coping skills and cognitive strategies without using drugs or alcohol. Each of the high-risk relapse stages in HIV disease is examined, including individual real-life situations, followed by discussions on how alcohol and drug relapse prevention may prove helpful in getting HIV-infected patients to adhere to their treatment regimens. Prevention strategies to reduce risk for HIV disease, coping skills that effect relapse, and ways that physicians with knowledge of and training in chemical dependency can help patients in preventing relapses are discussed. Individuals who abstain from alcohol and drugs may benefit from stronger immune systems and may by less likely to engage in unsafe sexual behavior. Tables list the eight high-risk factors that may lead to relapse of alcohol and drug abuse, and provide the five components of relapse prevention.


  • T. J. Gallagher, L. B. Cottler, W. M. Compton & E. Spitznagel, (1997)  Changes in HIV/AIDS risk behaviors in drug users in St Louis: applications of random regression models. Journal of Drug   Issues . Volume (Issue):  27(2) pp. 399-416.


A National Institute on Drug Abuse demonstration project in AIDS prevention among drug users was conducted in St Louis during the years 1990 through 1994. The main objective was to reduce the spread of HIV by counselling drug users and by improving drug-treatment programmes in the area. A second objective was to examine the correlates of risk behaviour. A structured interview was administered six times over an 18-month period. Of those persons assessed at baseline (n = 475), 95.0 percent (n = 451) were also re-interviewed in the last interview at 18 months. Both group and individual level changes in risk behaviour were assessed using random regression models. The authors report on three potential risk behaviours for HIV/AIDS: (1) number of sexual partners; (2) frequency of condom use; and (3) injection drug use. For each risk behaviour a separate statistical model was estimated. The results of the random regression models showed significant reductions in number of sexual partners and injection drug use. Additionally, a number of variables, such as perceived risk for AIDS and knowledge of HIV/AIDS, were statistically significant covariates of risk behaviour.


  • TK Logan, , Jennifer Cole and Carl Leukefeld .2002. Women, Sex, and HIV: Social and Contextual Factors, Meta-Analysis of Published Interventions, and Implications for Practice and Research. Psychological Bulletin , Volume 128, Issue 6 , November 2002, Pages 851-885 


This article is focused on examining social and contextual factors related to HIV-risk behaviour for women. Specifically, this article has three main purposes: to review the literature on selected social and contextual factors that contribute to the risk for the heterosexual transmission of HIV and AIDS, to review and conduct a meta-analysis of HIV-prevention interventions targeting adult heterosexual populations, and to suggest future directions for HIV-prevention intervention research and practice. Results suggest that the HIV-prevention interventions reviewed for this article had little impact on sexual risk behavior, that social and contextual factors are often minimally addressed, and that there was a large gap between research and the practice of HIV-prevention intervention.


  • T. Myers, R. Cockerill, C. Worthington, M. Millson & J. Rankin, (1998) Community pharmacist perspectives on HIV/AIDS and interventions for injection drug users in Canada. AIDS . Volume (Issue):  10(6) pp. 689-700.


In several countries, community pharmacies play a major role in the provision of HIV prevention services to injection drug users (IDUs). In this study, results from a national Canadian Survey of Community Pharmacies and HIV/AIDS Prevention are used to describe pharmacists' perspectives on HIV/AIDS and services to IDUs and explore the relationship between personal and organisational characteristics and the level of support for HIV/AIDS prevention initiatives. A mailed questionnaire was directed to a random sample of 2,017 pharmacist owner-managers. The response rate was 84.6 percent. Results suggest that current services to IDUs primarily are limited to discretionary needle and syringe sales to non-diabetics, with almost three-quarters supportive. Staff safety was an important consideration in the provision of this service (77 percent), while remuneration was the lowest (27 percent). Community pharmacists were most comfortable with the provision of counselling, advice and literature (X = 2.6) and environmental and technological interventions (X = 2.4) and least supportive of provision of services as part of a programme (X = 1.6) and legalisation of drugs or prescription of methadone (X = 1.9). Female pharmacists were more likely to support preventive measures such as the provision of counselling or advice and males were more likely to promote legislative change. Pharmacists appear generally willing to expand their services in the fight against HIV/AIDS. However, it is not feasible to expect uniform programmes to be immediately introduced. While organisational, educational and policy changes may facilitate programme development, individual pharmacy and pharmacist discretion remains important. 


  • W. M. Loxley, J. S. Bevan & S. J. Carruthers,(1997) Age and injecting drug use revisited: the Australian Study of HIV and Injecting Drug Use. AIDS Care . Volume (Issue):  9(6) pp. 661-670.


In 1991 the authors reported on differences between younger and older injecting drug users (IDUs) in the Australian National AIDS and Injecting Drug Use Study. In 1994, a second large multi-city study of IDUs, the Australian Study of HIV and Injecting Drug Use (ASHIDU) allowed a repetition of that analysis to see whether age differences demonstrated in 1991 could still be found. Using discriminant function analysis, they found that younger (under 23) IDUs were more likely than older IDUs to be female, to have used hallucinogens in the previous month and to have used condoms during the last sexual encounter; and less likely to be in drug treatment. Young IDUs were more mobile, injected in larger groups, had had fewer HIV/AIDS tests and used tranquillisers less frequently than older IDUs. These differences are similar in some respects to those found in 1991, but there were no differences in needle sharing as were found in 1991. The social context of younger IDUs' lives and drug use and the difficulty in accessing them through drug treatment agencies are noted as factors to be taken into consideration when designing harm reduction strategies for this group. 


  • W. DiFranceisco, J. A. Kelly, L. Otto-Salaj, et al. (1999) Factors influencing attitudes within AIDS service organizations toward the use of research-based HIV prevention interventions. AIDS Education and Prevention . Volume (Issue):  11(1) pp. 72-86.


Although the efficacy of small-group, risk reduction interventions based on cognitive behavioural principles has been widely documented in HIV behavioural research literature, little is known about how AIDS service organisations (ASOs) view these research-based models. From a nation-wide sample of 77 ASOs, this study assessed factors influencing attitudes of prevention program directors and frontline staff towards research-based interventions. Characteristics of individual respondents as well as organisational characteristics of the ASO itself were used to predict perceived benefits of adopting this type of intervention, perceived efficacy (confidence) in the ASO's ability to implement it and perceived barriers to adoption. Findings revealed uniformly positive perceptions of benefits among respondents from ASOs of different sizes and organisational experiences, although directors held more favourable evaluations than frontline staff. Respondents from ASOs that were larger, had previously delivered group or workshop interventions or had received outside technical assistance in the past expressed more confidence in the ability of their ASO to implement the intervention. On the other hand, older and more highly educated individuals had less confidence in their organisation's ability to implement the model. Resource constraints (money, staff and time) were the most common barriers cited by the respondents. Overall, higher organisational role and longer tenure at an ASO were associated with the perception of more barriers to adopting science-based interventions. 


  • Editorial. HIV, harm reduction and human rights. BMC Public Health. 2003; 3: 37.

One of the most important facts about the global AIDS epidemic facing us in 2005 is that 10% of new HIV infections are now related to illicit injection drug use. Outside Africa, at least one in three new infections results from the sharing of a contaminated needle. Russia, China, Malaysia, Ukraine and Vietnam have entrenched epidemics in which most cases are related to injection drug use. Injection drug use accounts for most cases in Tajikistan, Kazakhstan, Uzbekistan, Iran, Indonesia and Nepal and is the leading mode of transmission in most of Western and Eastern Europe, North Africa, and the Middle East.1

The fact that there are an estimated 13 million injection drug users (IDUs) in the world makes this state of affairs all the more urgent. As the authors of a report to the UN Millennium Project note, "injection-driven epidemics are ... distinguished by the extreme rapidity of their spread."1 The soaring infection rates among IDUs are in large measure the byproduct of a law-enforcement approach to drug policy, which deepens the social isolation of IDUs and presents barriers to harm-reduction strategies such as needle exchange and opioid substitution therapy. In some contexts, the paradoxical effects of the "war on drugs" are even more complex: "Law enforcement efforts restricting opium supplies lead users to shift to heroin use, or from smoking to injection. Criminalization of needle possession encourages use of shooting galleries or contaminated injection equipment."1 In many jurisdictions, the prisons and "treatment centres" where IDUs are incarcerated are themselves sites of drug trafficking, needle sharing and unprotected sex where harm-reduction measures are denied on the grounds that they condone criminal behaviour.

Another layer to this miserable picture is the generally poor access to antiretroviral (ARV) therapies among IDUs, even in developed countries. The WHO's "3 by 5" initiative to deliver ARV therapy to 3 million people by the end of 2005 has brought the number of recipients from 440 000 to 700 000, but this number accounts for only 12% of those who need it. Although the WHO has stipulated that ARV therapy should be made available to all, some jurisdictions report that none of the recipients of ARV therapy are IDUs.2 (A notable exception is Brazil, where a comprehensive harm-reduction and drug-access program reduced AIDS mortality among IDUs by 50%.)

As Richard Elliott and colleagues discuss in this issue (see page 655),3 a harm-reduction approach to HIV control among IDUs is at odds with the prevailing framework of international drug control, which rests on law enforcement and the criminalization of behaviours related to illicit drug use. Treatment and rehabilitation are given lip service within the UN Drug Conventions, but the liberalization of drug policy and attempts to replace (or at least supplement) failed law enforcement policies with harm-reduction strategies have proceeded at a snail's pace.

Elliott and colleagues argue for a small but significant policy change as a matter of both pragmatism and human rights: namely, to promote access of IDUs to medical care by adding opioid substitutes to the WHO's Model List of Essential Medicines. In 1977 the WHO published its first such list: 208 therapeutic agents deemed to be the most efficacious, cost-effective and safe treatments available against the majority of infectious and chronic diseases, a pharmacologic tool kit needed by any health system that hopes to serve its population's basic health care needs and rights. From March 7-11 the UN Committee on the Selection and Use of Essential Medicines will consider applications for changes to the list; among those proposed are the addition of the opioid substitutes methadone and buprenorphine. We hope that including opioid substitutes to the WHO-endorsed pharmacopeia will give timely support to the establishment and wider use of addiction treatment programs, and in so doing will help more IDUs to come inside the tent of HIV treatment and prevention. - CMAJ


© 2006 UNODC