Sex, drugs and HIV counseling and testing: a prospective study of behavior-change among methadone-maintenance clients in New England.

OBJECTIVES: To determine whether changes in injecting drug use and sexual behavior over a 12-month follow-up are associated with HIV counseling and testing (C and T) of injecting drug users in methadone maintenance treatment programs (MMTP) in Massachusetts and Connecticut. METHODS: Clients were invited to participate in a longitudinal study involving five interviews. Data were also obtained by ethnographers and from clinical records. Behavioral outcomes of interest were number of drug injections, sharing of unclean 'works' (injecting equipment), number of unprotected sex partners, and number of unprotected sexual episodes. Data analyses included multiple regression, odds ratios, and quantitative analysis of text-based data. RESULTS: Subjects reported reductions in both injecting drug use and sexual behavior Primary associations with reduced injecting drug use were remaining in the MMTP and attending HIV-positive support groups. A reduction in high-risk sexual behavior was associated with an HIV-positive test result and duration of HIV counseling in the MMTP. Increase in drug injecting use was associated with an HIV-positive test result. Inconsistent condom use was associated with enrollment in the MMTP where condoms were available only upon request and abstinence and monogamy between uninfected partners were promoted. CONCLUSIONS: Injecting drug users who self-select to participate in MMTP and HIV C and T, two public health HIV-prevention interventions, reduce their HIV-risk behaviors. Clients should be encouraged to remain in MMTP and HIV-infected clients should attend support groups for HIV-positive persons. MMTP staff should promote a variety of safer sex behaviors and provide condoms without request.

Retention in methadone maintenance treatment programs, Connecticut and Massachusetts, 1990-1993.

The goal of this study was to identify factors associated with six- and 12-month retention in methadone maintenance treatment programs (MMTPs) in Massachusetts and Connecticut. Data was obtained from 674 participants, clinic records, and clinic staff. Ethnographic and logistic regression analyses were conducted. Overall, 69% and 48% of the clients remained in treatment at six months and 12 months, respectively. The MMTPs were categorized as either a 12-Step, case management, or primary care model. Factors independently associated with retention in treatment at six months were each one-year increase in age of client (OR 1.05), injecting at three months (OR 0.47), and enrollment in the primary care model (OR 2.10). The same factors were associated with 12-month retention in treatment. To retain clients in MMTPs-which should, in turn, help reduce drug use and prevent HIV transmission among IDUs-younger IDUs and clients still injecting at three months after entering drug treatment may need additional services from the staff, or alternative treatment regimens. MMTP directors should consider differences between these programs and, if appropriate, make changes to increase retention in treatment.

Prevention of HIV infection in drug abusers: a cost analysis.

BACKGROUND: Counseling and testing for HIV infection is performed at many sites, including drug treatment centers. The actual cost of providing HIV counseling and testing at drug treatment sites, based upon empirical data collection, has not been reported. The average lifetime medical cost for an HIV-infected individual is $56,000. This study provides both a systematic method for estimating HIV counseling and testing costs and actual cost results. These results can be compared with the medical costs associated with HIV infection. METHODS: At three publicly funded methadone treatment centers, we collected cost data on the provision of HIV counseling and testing. We obtained provider service times for HIV counseling and testing components, provider salaries and fringe rates, laboratory costs, and support costs at each center. RESULTS: The average cost of HIV counseling and testing is $215 per client entering HIV counseling and testing and $341 per client made aware of HIV serostatus. The total direct cost of providing HIV counseling and testing is $41 for an HIV-negative client who completes the process and $57 for an HIV-positive client; the support costs add an additional $175 per client. CONCLUSIONS: Existing methadone maintenance treatment clinics planning to add HIV counseling and testing can expect costs in a range of $189 to $242 per person entering HIV counseling and testing (1991 dollars). Using an average lifetime cost of HIV infection ($56,000) and the average cost per person entering HIV counseling and testing ($215), if more than 1 person in 260 changes his or her behavior to prevent one additional HIV infection, the ratio of medical care savings to costs of counseling and testing would be greater than 1.0, a cost-saving prevention strategy.

Evaluating the CDC program for HIV counseling and testing.

The Centers for Disease Control is conducting two investigations of the outcomes of HIV counselling and testing services offered persons at high risk for infection with the human immunodeficiency virus (HIV). One investigation is a trial conducted at sexually transmitted disease clinics where an enhanced version of HIV counseling and testing is compared with a standard version. The other investigation is a longitudinal study of the effects of HIV counseling and testing in drug treatment programs that use methadone therapy. In the evaluation, comparisons are being made of different ways of offering HIV counseling and testing and of the effectiveness of the program among persons who know their HIV serostatus and those who do not. The outcome variables include self-reported sexual and drug-using behaviors, together with corroborating laboratory tests, drug treatment compliance, mental health effects, and services utilization. Methodological, practical, and sociopolitical challenges were encountered in the evaluations. Possible solutions to the problems are described. The authors conclude that the designs of the evaluations were appropriate, but that considerable resources are required to carry them out. In settings with low levels of resources, thorough evaluation of the process and an assessment of the immediate outcomes may be the most appropriate evaluation strategy. As HIV counseling and testing are of fundamental importance to national and international HIV prevention efforts, their evaluation is a critical issue.