Intended for healthcare professionals

  1. Research
  2. Opiate substitution...
  3. Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis
CCBYNC Open access
Research

Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5945 (Published 04 October 2012) Cite this as: BMJ 2012;345:e5945
  1. Georgie J MacArthur, academic public health training fellow1,
  2. Silvia Minozzi, medical doctor and clinical epidemiologist2,
  3. Natasha Martin, research fellow in mathematical modelling13,
  4. Peter Vickerman, senior lecturer in mathematical epidemiology14,
  5. Sherry Deren, director, senior research scientist5,
  6. Julie Bruneau, professor6,
  7. Louisa Degenhardt, professor and NHMRC senior research fellow78,
  8. Matthew Hickman, professor in public health and epidemiology1
  1. 1School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK
  2. 2Lazio Regional Health Service, Department of Epidemiology, Cochrane Drugs and Alcohol Group, Rome, Italy
  3. 3Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
  4. 4Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London
  5. 5Center for Drug Use and HIV Research, New York University College of Nursing, New York City, USA
  6. 6Research Centre (CRCHUM), Centre Hospitalier de l’Université de Montréal, Montreal, Canada
  7. 7National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
  8. 8University of Melbourne, Centre for Health Policy, Programs and Economics, Melbourne, Australia
  1. Correspondence to: G J MacArthur georgie.macarthur{at}bristol.ac.uk
  • Accepted 24 August 2012

Abstract

Objective To quantify the effect of opiate substitution treatment in relation to HIV transmission among people who inject drugs.

Design Systematic review and meta-analysis of prospective published and unpublished observational studies.

Data sources Search of Medline, Embase, PsychINFO, and the Cochrane Library from the earliest year to 2011 without language restriction.

Review methods We selected studies that directly assessed the impact of opiate substitution treatment in relation to incidence of HIV and studies that assessed incidence of HIV in people who inject drugs and that might have collected data regarding exposure to opiate substitution treatment but not have reported it. Authors of these studies were contacted. Data were extracted by two reviewers and pooled in a meta-analysis with a random effects model.

Results Twelve published studies that examined the impact of opiate substitution treatment on HIV transmission met criteria for inclusion, and unpublished data were obtained from three additional studies. All included studies examined methadone maintenance treatment. Data from nine of these studies could be pooled, including 819 incident HIV infections over 23 608 person years of follow-up. Opiate substitution treatment was associated with a 54% reduction in risk of HIV infection among people who inject drugs (rate ratio 0.46, 95% confidence interval 0.32 to 0.67; P<0.001). There was evidence of heterogeneity between studies (I2=60%, χ2=20.12, P=0.010), which could not be explained by geographical region, site of recruitment, or the provision of incentives. There was weak evidence for greater benefit associated with longer duration of exposure to opiate substitution treatment.

Conclusion Opiate substitution treatment provided as maintenance therapy is associated with a reduction in the risk of HIV infection among people who inject drugs. These findings, however, could reflect comparatively high levels of motivation to change behaviour and reduce injecting risk behaviour among people who inject drugs who are receiving opiate substitution treatment.

Footnotes

  • We thank Jonathan Sterne for helpful advice regarding data analyses and Ali Judd for providing unpublished data for our analyses regarding HIV incidence and exposure to opiate substitution treatment among people who inject drugs.

  • Contributors: MH was responsible for conception of study; MH and GJM were responsible for design of the study; GJM for literature searching and data analyses. SM, NM, PV and MH contributed to the screening and data extraction. SD and JB contributed unpublished data for the study. GJM wrote the first draft of the manuscript and all authors contributed to interpretation of data and critical revision of the article for intellectual content. MH is guarantor.

  • Funding: GJM is funded by the South West Public Health Training Scheme; PV is funded by an MRC New Investigators Award (G0701627); MH is supported by the Nationally Integrated Quantitative Understanding of Addiction Harm (NIQUAD) MRC addiction research cluster. The work was undertaken with the support of The Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), a UKCRC Public Health Research: Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council (RES-590-28-0005), Medical Research Council, the Welsh Assembly Government and the Wellcome Trust (WT087640MA), under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged. The funders had no role in the design, execution, and writing up of the study.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: JB has received funding from Merck to attend a scientific meeting unrelated to this study; LD has received two educational grants from Reckitt Benckiser (they had no role in any aspect of study design, conduct, analysis, interpretation, or publication and have no knowledge of this current study). LD has received payment to deliver a presentation at a conference organized by Pfizer; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

View Full Text
Back to top