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Review
. 2012 Oct 3:345:e5945.
doi: 10.1136/bmj.e5945.

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

Georgie J MacArthur  1 , Silvia Minozzi, Natasha Martin, Peter Vickerman, Sherry Deren, Julie Bruneau, Louisa Degenhardt, Matthew Hickman
Affiliations
Review

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

Georgie J MacArthur et al. BMJ. .

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Design: Systematic review and meta-analysis of prospective published and unpublished observational studies.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studies that examined the impact of opiate substitution treatment on HIV transmission met criteria for inclusion, and unpublished data were obtained from three additional studies.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 (I(2)=60%, χ(2)=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.

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Conflict of interest statement

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.

Figures

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Fig 1 Selection of studies directly investigating impact of opiate substitution treatment on HIV transmission
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Fig 2 Selection of prospective cohort studies relating to HIV incidence in people who inject drugs. Of seven identified, two were included in sensitivity or subgroup analyses only
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Fig 3 Meta-analysis of studies showing impact of opiate substitution treatment in relation to HIV transmission in people who inject drugs among all pooled studies and studies reporting only adjusted effect estimates
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Fig 4 Impact of opiate substitution treatment in relation to HIV incidence among people who inject drugs by geographical region
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Fig 5 Impact of opiate substitution treatment in relation to HIV incidence among people who inject drugs by site of recruitment of study participants
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Fig 6 Meta-analysis of included studies showing impact of detoxification treatment on incident HIV infection among people who inject drugs compared with either no treatment or methadone maintenance treatment
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