Substitution treatment of injecting opioid users for prevention of HIV infection

Linda Gowing; Michael Farrell; Reinhard Bornemann; Robert Ali

doi:10.1002/14651858.CD004145.pub2

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Analysis 1.1

Comparison 1 Drug use and risk outcomes (follow‐up studies), Outcome 1 Proportion reporting injecting use.

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Analysis 1.2

Comparison 1 Drug use and risk outcomes (follow‐up studies), Outcome 2 Proportion sharing injecting equipment.

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Analysis 1.3

Comparison 1 Drug use and risk outcomes (follow‐up studies), Outcome 3 Opioid use (proportion reporting use or with positive urine samples).

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Analysis 1.4

Comparison 1 Drug use and risk outcomes (follow‐up studies), Outcome 4 Cocaine use (proportion using or with positive urine screens).

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Analysis 2.1

Comparison 2 Sex‐related risk outcomes (follow‐up studies), Outcome 1 Proportion reporting multiple sex partners.

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Analysis 2.2

Comparison 2 Sex‐related risk outcomes (follow‐up studies), Outcome 2 Proportion reporting unprotected sex (or use of condoms in half or less of occasions).

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Analysis 2.3

Comparison 2 Sex‐related risk outcomes (follow‐up studies), Outcome 3 Proportion reporting exchanges of sex for drugs or money.

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Analysis 3.1

Comparison 3 Overall risk assessments (follow‐up studies), Outcome 1 Proportion at risk.

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Analysis 4.1

Comparison 4 Drug use and risk outcomes ‐ substitution treatment versus no substitution treatment, Outcome 1 Proportion reporting injecting use.

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Analysis 4.2

Comparison 4 Drug use and risk outcomes ‐ substitution treatment versus no substitution treatment, Outcome 2 Frequency of injecting use.

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Analysis 4.3

Comparison 4 Drug use and risk outcomes ‐ substitution treatment versus no substitution treatment, Outcome 3 Proportion sharing injecting equipment.

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Analysis 4.4

Comparison 4 Drug use and risk outcomes ‐ substitution treatment versus no substitution treatment, Outcome 4 Frequency of opioid use.

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Analysis 4.5

Comparison 4 Drug use and risk outcomes ‐ substitution treatment versus no substitution treatment, Outcome 5 Frequency of cocaine use.

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Analysis 4.6

Comparison 4 Drug use and risk outcomes ‐ substitution treatment versus no substitution treatment, Outcome 6 Drug risk scores.

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Analysis 5.1

Comparison 5 Sex‐related risk outcomes ‐ substitution treatment versus no substitution treatment, Outcome 1 Sex‐related risk score.

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Analysis 5.2

Comparison 5 Sex‐related risk outcomes ‐ substitution treatment versus no substitution treatment, Outcome 2 Number of sex partners.

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Analysis 5.3

Comparison 5 Sex‐related risk outcomes ‐ substitution treatment versus no substitution treatment, Outcome 3 Proportion reporting unprotected sex (or use of condoms in half or less of occasions).

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Analysis 5.4

Comparison 5 Sex‐related risk outcomes ‐ substitution treatment versus no substitution treatment, Outcome 4 Frequency of condom use.

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Analysis 5.5

Comparison 5 Sex‐related risk outcomes ‐ substitution treatment versus no substitution treatment, Outcome 5 Proportion reporting exchanges of sex for drugs or money.

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Analysis 5.6

Comparison 5 Sex‐related risk outcomes ‐ substitution treatment versus no substitution treatment, Outcome 6 Frequency of exchanges of sex for drugs or money.

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Table 1. Nature of substitution treatment

Study	Substitute agent	Av. dose/day	Setting
Abbott 1998	Methadone	About 70mg	Specialist drug & alcohol program
Avants 1998	Methadone	About 80mg	Specialist drug & alcohol program
Baker 1995	Methadone	About 66mg	Not reported
Batki 1989	Methadone	Not reported	Specialist AIDS program
Britton 1994	Methadone	Not reported	Specialist drug & alcohol program
Brooner 1998	Methadone	70mg	Specialist drug & alcohol program
Camacho 1996	Methadone	About 40mg	Specialist drug & alcohol program
Chatham 1999	Methadone	About 40mg	Specialist drug & alcohol program
Dolan 2003	Methadone	61mg	Prison methadone program
Finch 1995	Methadone	About 50mg	Specialist drug & alcohol program
Gossop 2000	Methadone	About 50mg	Specialist drug & alcohol program & primary health
Grella 1996	Methadone	Not reported	Specialist drug & alcohol program
Iguchi 1998	Methadone	40mg/day (taper)	Specialist drug & alcohol program
King 2000	Methadone	50mg/day	Specialist drug & alcohol program
Kwiatkowski 2001	Methadone	70mg/day	Specialist drug & alcohol program
Maddux 1997	Methadone	Not reported	Specialist drug & alcohol program
Magura 1991	Methadone	Not reported	Specialist drug & alcohol program
Margolin 2003	Methadone	˜80mg/day	Specialist drug & alcohol program
Meandzija 1994	Methadone	Not reported	Not reported
Metzger 1993	Methadone	About 44mg	Specialist drug & alcohol program
Sees 2000	Methadone	Not reported	Not reported
Moss 1994	Methadone	About 85mg	Not reported
Serpelloni 1994	Methadone	Not reported	Specialist drug & alcohol program
Simpson 1995	Methadone	Not reported	Specialist drug & alcohol program
Stark 1996	Methadone	80‐100mg/day	Not reported
Strang 2000	Methadone	57mg/day	Specialist drug & alcohol program
Thiede 2000	Methadone	Not reported	Specialist drug & alcohol program
Williams 1992	Methadone	70mg/day	Specialist drug & alcohol program

Table 1. Nature of substitution treatment

Study	Characteristics	Recruitment	Confounders	Follow‐up	Intervention	Data collection	Overall risk
Abbott 1998	0	0	0	0	0	0	0
Avants 1998	0	0	0	0	0	0	0
Baker 1995	1	0	1	0	0	0	2
Batki 1989	0	1	0	1	0	0	2
Britton 1994	1	1	1	0	0	0	3
Brooner 1998	1	1	1	0	0	0	3
Camacho 1996	0	0	0	1	0	0	1
Chatham 1999	0	0	0	1	0	0	1
Dolan 2003	0	0	0	1	0	0	1
Finch 1995	0	1	0	1	0	0	2
Gossop 2002	0	0	0	1	0	0	1
Grella 1996	0	1	0	0	0	1	2
Iguchi 1998	0	0	0	1	0	0	1
King 2000	1	0	0	0	0	0	1
Kwiatkowski 2001	0	0	1	1	0	0	2
Maddux 1997	0	0	1	0	0	0	1
Magura 1991	0	0	0	1	0	0	1
Margolin 2003	1	0	0	1	0	1	3
Meandzija 1994	1	0	1	0	0	0	2
Metzger 1993	0	0	1	0	0	0	1
Moss 1994	1	1	1	0	1	0	4
Sees 2000	0	0	1	1	0	0	2
Serpelloni 1994	1	0	0	0	1	0	2
Simpson 1995	0	0	0	1	0	0	1
Stark 1996	0	0	1	0	0	0	1
Strang 2000	0	0	0	1	0	0	1
Thiede 2000	0	0	1	1	0	0	2
Williams 1992	1	0	1	1	0	1	4
Total studies	9	6	12	15	2	3	‐

Study	Interval
Abbott 1998	6 months
Avants 1996	6 months after completion of 12‐week program
Baker 1995	No follow‐up ‐ single interview
Batki 1989	12 months ‐ 3 months also available
Britton 1994	12 months
Brooner 1998	1 month
Camacho 1996	6 months ‐ 3 months also available
Chatham 1999	12 months after leaving study
Dolan 2003	4 months
Finch 1995	2 months
Gossop 2000	1 year (primary data)
Grella 1996	18‐24 months
Iguchi 1998	5‐6 weeks (1‐2 weeks also available)
King 2000	6 months
Kwiatkowski 2001	6 months
Maddux 1997	12 months
Magura 1991	12 months
Margolin 2003	6 and/or 9 months
Meandzija 1994	No follow‐up ‐ single interview
Metzger 1993	18 months
Moss 1994	Not applicable
Sees 2000	6 months (12 months also available)
Serpelloni 1994	Not applicable
Simpson 1995	3 months
Stark 1996	No follow‐up ‐ single interview
Strang 2000	6 months
Thiede 2000	12 months
Williams 1992	Not applicable

Study	Proportion injecting
Abbott 1998	Not reported ‐ 47% new to methadone
Avants 1998	214/291 (73.5%) entering treatment using iv
Baker 1995	Injecting use in prior 6 months a requirement
Batki 1989	All injecting drug users
Britton 1994	All in MMT at baseline ‐ unclear how many injecting
Brooner 1998	Unclear
Camacho 1996	All injected in 30 days prior
Chatham 1999	All injecting at entry
Dolan 2003	50% MMT and 56% control injected in prison prior to baseline interview
Finch 1995	98% injecting drug users
Gossop 2000	62% injecting at intake
Grella 1996	Unclear
Iguchi 1998	Unclear
King 2000	86% injected in 30 days prior to intake
Kwiatkowski 2000	Injecting use in prior 30 days a requirement
Maddux 1997	Unclear
Magura 1991	All injecting users at entry
Margolin 2003	Injecting drug use selection criterion
Meandzija 1994	Injecting drug users selected
Metzger 1993	87% injected in 6 months prior to baseline
Moss 1994	Injecting drug use selection criterion
Sees 2000	Unclear
Serpelloni 1994	Injecting drug users selected
Simpson 1995	Unclear
Stark 1996	Injecting drug use in prior 3 months required
Strang 2000	All injecting users
Thiede 2000	All injecting users
Williams 1992	Unclear (history of injecting use)

Study	Timeframe
Abbott 1998	Unclear (possibly 30 days)
Avants 1998	Unclear
Baker 1995	Prior month
Batki 1989	Prior 30 days
Britton 1994	Prior 6 months
Brooner 1998	Prior 30 days
Camacho 1996	Prior 30 days
Chatham 1999	Prior 6 months
Dolan 2003	1 month (3x1 month periods prior to follow‐up)
Finch 1995	Unclear
Gossop 2000	Prior 90 days
Grella 1996	Prior 30 days or prior 12 months
Iguchi 1998	Combination of 2 assessments, each of 1 week
King 2000	Prior 30 days
Kwiatkowski 2001	Prior 30 days
Maddux 1997	Prior 30 days
Magura 1991	Prior 30 days
Margolin 2003	Variable
Meandzija 1994	Prior 30 days
Metzger 1993	Prior 6 months
Moss 1994	Not applicable
Sees 2000	Prior 6 months
Serpelloni 1994	Not applicable
Simpson 1995	Prior 30 days
Stark 1996	Prior 6 months
Strang 2000	Prior 30 days
Thiede 2000	1 month prior
Williams 1992	Not applicable

Study and group	Group size	Measure	Baseline status	Follow‐up status	Significance
Batki 1989	42	Days in past 30	27.5	6.3	significant
Brooner 1998, referred from (1) needle exchange (2) standard sources	(1) 66 (2) 203	Days in prior 30	(1) 24.08 (2) 6.68	(1) 13.70 (2) 3.82	Tukey's HSD (1) 0.01 (2) 0.01
Camacho 1996	326	Frequency in prior 30 days	111 ± 59.5	6 ± 19.3	P < 0.001
Chatham 1999	435	Frequency score for prior 6 months	7.3 ± 1.0	3.6 ± 3.1	P < 0.001
Dolan 2003 (1) methadone maintenance (2) wait‐list control	(1) 129 (2) 124	Times heroin injected in prior month	(1) 9 (2) 15	(1) 1.3 (2) 8.5	P < 0.001
Kwiatkowski 2001, (1) methadone maintenance & risk reduction (2) risk reduction only	(1) 99 (2) 216	Heroin injections in prior month	(1) 77.1 ± 39.9 (2) 60.1 ± 37.4	(1) 22.9 ± 35.9 (2) 36.3 ± 44.5	P < 0.01
Simpson 1995	521	Injections in last 30 days	108 ± 57.6	9.5 ± 47.4	P < 0.001
Strang 2000	15 baseline, 11 follow‐up	Days in past 30	20.1 ± 9.9	11.9 ± 11.7	P < 0.001

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Proportion reporting injecting use Show forest plot	6		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

1.1 Controlled studies	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Cohort studies	0		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 Descriptive studies	5		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
2 Proportion sharing injecting equipment Show forest plot	7		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

2.1 Controlled studies	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Cohort studies	0		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
2.3 Descriptive studies	6		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
3 Opioid use (proportion reporting use or with positive urine samples) Show forest plot	7		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

3.1 Controlled studies	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 Cohort studies	0		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
3.3 Descriptive studies	6		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
4 Cocaine use (proportion using or with positive urine screens) Show forest plot	4		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4.1 Controlled studies	0		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
4.2 Cohort studies	0		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
4.3 Descriptive studies	4		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]

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