Copenhaver MM, Johnson BT, Lee IC, Harman JJ, Carey MP; SHARP Research Team. Behavioral HIV Risk Reduction Among People Who Inject Drugs: Meta-Analytic Evidence of Efficacy. J Subst Abuse Treat. 2006 Sep;31(2):163-71.
Using meta-analysis to summarize behavioral HIV risk-reduction interventions targeting injection drug users (IDU).
Only randomized controlled trials (RCT) were included in this meta-analysis. To qualify, a study had to: 1) evaluate group or individual behavioral HIV prevention interventions; 2) include a sample of at least 50% of people who reported injecting drugs; 3) include intravenous drug-use-related behavioral outcomes; 4) use an RCT design; and 5) provide statistical information for the calculation of effect size (ES).
Four overlapping strategies were used: 1) searches for terms such "HIV," "AIDS," "human and immune* and virus," "acquired and immune* and syndrome," and "intervene* and prevent* paired with (needle* or inject*, or idu or IDU, or IVDU or ivdu)" in the electronic databases of Medline, PsycINFO, AIDSLINE, CINAHL, Dissertation Abstracts Online, and ERIC; 2) requests for articles sent to authors and e-mail listservs; 3) search of reference sections within articles already obtained; and 4) manual search for conference proceedings and professional journals that are not available electronically. Studies that were available as of March 30, 2004 and that fit the inclusion criteria were analyzed.
There was a total of 10,190 participants in the 37 studies included in this analysis. Participants' mean age was 35 years and 61% were male. The samples were ethnically diverse, with 51% African American, 29% Caucasian, and 20% Latino. A majority (88%) reported recent IDU (within the past three months), 46% reported recent needle sharing or borrowing, and 29% reported recent sex trading.
A total of 37 RCTs evaluating 49 independent HIV risk-reduction interventions were included in this analysis. Seventy-eight percent of the studies were published in peer-reviewed journals; 20% were studies from individual sites that were published in the public domain report of the National AIDS Demonstration Research (NADR) project; and 2% were from unpublished documents. Of the studies, 51% implemented a brief HIV risk-reduction intervention as control condition, whereas 22% used HIV/AIDS education only, 20% adopted a wait-list treatment/no treatment, 4% used substance abuse treatment only, and 2% used an intervention with non-HIV content as control. Most interventions included the following components: HIV/AIDS education (90%), condom use (69%), self-management skills (57%), and both drug-related and sex-related risk reduction (70%). All studies were conducted in the United States; one of these was conducted in Puerto Rico.
The behavioral outcomes included in this analysis were: 1) frequency of IDU; 2) frequency of non-IDU; 3) frequency of sharing needles/equipment; 4) frequency of bleaching needles/equipment; 5) entry into drug treatment; 6) frequency of condom use; 7) frequency of sex-related HIV risk behavior; and 8) frequency of trading sex for drugs.
Using data from the first assessment after the completion of the intervention, participants significantly: 1) reduced IDU (weighted mean effect size [ES or d]=0.08, 95% CI=0.03-0.13); 2) decreased non-IDU (d=0.18, 95% CI=0.06-0.30); 3) increased entry into drug treatment (d=0.11; 95% CI=0.02-0.21); 4) increased condom use (d=0.19, 95% CI=0.11-0.26); and 5) reduced frequency of trading sex for drugs (d=0.33, 95% CI=0.10-0.57). Interventions were more successful at reducing IDU when participants were non-Caucasians, when content focused equivalently on drug-related and sex-related risks, and when content included interpersonal skills training specific for safer needle use. No decay was found in the IDU outcomes; however, condom outcomes decayed over time. Condom use outcomes improved when two intervention facilitators were used instead of one.
The authors conclude that behavioral interventions reduce risk behaviors among people who inject drugs, especially when interventions target both drug risk and sexual risk behaviors, and when they include certain behavioral skills components.
Based on the QUOROM grading system for systematic reviews, this study is of high quality. The study is limited by: 1) the unavailability of studies with long-term follow up, making it difficult to assess long-term outcomes and; 2) the inclusion of studies whose outcomes were based only on self-reported data. These limitations are the result of available research rather than the methods the authors employed.
As in previous reviews, this review observed modest ES on risk behavior outcomes.(1,2,3) These effects may reflect the use of control conditions that are similar to, although briefer than, the intervention being evaluated. Although this design feature is ethically necessary, it inadvertently limits the range of ES that might be observed from the literature. However, the modest behavior changes reported here and in prior reviews have the potential to improve public health, especially when extrapolated to high-risk populations.(1,4)
Some specific results from this review may be useful in the development of HIV behavioral interventions for intravenous drug users. For example, interventions were more successful at reducing IDU for non-Caucasians. In addition, reduced IDU was more likely when interventions provided interpersonal skills training specific for safer needle use. However, maintaining consistent condom use over time may require additional strategies, such as additional booster sessions. Note that with the exception of one study in Puerto Rico, all studies in this systematic review were conducted in the United States, which may limit the generalizability of its findings to other cultural, social and legal settings.
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