There is now a large and growing body of research demonstrating thepositive relationship between effective treatments for substance abuse and reductions in risky behaviors and HIV infection. The consistency of this relationship over time and across cultural settings is impressive and serves as a reminder that drug abuse and dependence, like other medical conditions, respond in a reliable and predictable manner when treated using evidence based approaches. The strongest evidence for this relationship has been derived from studies of methadone treatment. This data has been used to support the expansion of methadone treatment and the use of other The underlying mechanism of action is assumed to be the ability of medication assisted treatments for opiate dependence to address both the biological and behavioral components of abuse and dependence.
Importantly, there is increasing evidence of the positive effects of medication assisted treatments other than methadone. Studies of buprenorphine/naloxone and naltrexone now appear in the literature and are producing findings consistent with those of methadone treatment. This is particularly important considering the need for treatment multiple options in communities affected by HIV and other blood borne and sexually transmitted infections.
The recent literature significantly expands our understanding of the role of effective substance abuse treatments as HIV prevention by documenting its role in improving access and adherence to antiretroviral treatment. The data is clear and consistent. Through participation in substance abuse treatments, drug users have improved access to antiretroviral treatment, improved adherence to those treatments, and for those who remain in treatment, sustained reductions in viral load. These studies have also provided clear evidence that current use of substances, not past diagnoses is the critical factor in improved adherence. Thus, enrollment in drug treatment alone is not sufficient to achieve the positive effects of treatment. Rather, it’s the reduction in drug use that occurs among patients who are actively participating in their treatment. Thus, the data suggest that periodic screening of drug and alcohol use among individuals in HIV care is warranted.
Although the literature provides continued positive findings on drug treatment as HIV prevention there are limitations to the data. Still there have been no randomized controlled trials and as a consequence it is impossible to attribute risk reduction to the treatment alone. Given the important role of heroin injection in propelling the spread of HIV via injection related risk, most of the published research has involved opiate users and their treatment.
The findings that medication assisted treatments reduce use, risk behaviors, and infection with HIV have been widely promulgated, this has in some instances promoted the mere distribution of agonist medication. While such “low demand” interventions can help dependent individuals avoid withdrawal and reduce risk behaviors, these impacts will only be observed when the medication is available and used. The availability of methadone or buprenorphine without efforts to address the behavioral components of addiction cannot be expected to maximize efficacy and sustained impact.
The literature is quite clear that methadone treatment is an effective HIV prevention strategy and as reported here, early reports indicate that buprenorphine and buprenorphine-naloxone will produce similar protective effects. Unfortunately, comparable medication assisted treatments for cocaine and other stimulants are not currently available. While treatment strategies that do not use medications have shown some evidence of efficacy among high risk stimulant users, the development of a safe and effective treatment medication for stimulant abuse and dependence must remain a high priority.
Drug treatment programs can have an important role in reducing risk of HIV infection and transmission and in improving HIV treatment outcomes in many communities around the world. In order for this impact to be achieved, effective treatments must be available, accessible, and affordable. Currently, the vast majority of drug users do not have access to effective substance abuse treatments--even in countries considered to be more highly developed. 47
While data on the positive impacts of drug treatment may be a necessary condition for the development of policies that expand access, it is definitely not sufficient. The expansion of drug treatment access will continue to be dependent upon the combined efforts of basic research focused on medication development, operational research designed to demonstrate cost effective delivery strategies, and policy makers committed to the health of drug users and the communities in which they live.