Methadone and buprenorphine

The efficacy of drug treatment and, more specifically, opiate substitution therapies (e.g. MMT and buprenorphine) for HIV prevention has long been well established. The use of substitution therapies facilitates the transition from IDU to non-IDU, and is generally accompanied by a reduction in injection-related risk behavior (Drucker et al, 1998). In some treatment centers, sexual risk reduction counseling is also provided; however this is not universal (Sorensen and Copeland, 2000). In 1993, a prospective study by Metzger and colleagues demonstrated that the HIV incidence among methadone-treatment injection drug users was 3.5 percent compared with 22 percent in out of treatment users (Metzger et al, 1993). Further evidence has suggested that substitution therapies are most effective when initiated early in the course of an HIV epidemic (Ball et al, 1998; Drucker et al, 1998). In contrast, decreasing the availability of MMT has been associated with rapid increases in HIV, as evidenced by the Spanish epidemic (de la Fuente et al, 2003). However, despite the widespread evidence of the efficacy and effectiveness of MMT and buprenorphine, governments have been slow to officially adopt and fund such programs, and worldwide the availability of methadone treatment slots remains variable. Even in the United States, with the longstanding history of success of MMT, less than 15 percent of opiate addicts have access to MMT slots. MMT availability is further limited in parts of Eastern Europe and Asia (Grund, 1997; Drucker et al, 1998). Broader expansion of MMT is still plagued by the perception that it represents the substitution of one addiction for another and, in spite of the evidence of program success, MMT implementation continues to encounter resistance from abstinence-oriented practitioners.

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