# Presentation: 723333

## Behavioral Interventions for HIV Risk Reduction and HIV Prevention: An International Perspective

- Marek C. Chawarski
- Yale University School of Medicine

## HIV/AIDS cases among IDUs

**No Data Reported**

**0% HIV/AIDS cases among IDUs**

**< 10% HIV/AIDS cases among IDUs**

**10-40% HIV/AIDS cases among IDUs**

**40%+ HIV/AIDS cases among IDUs**

- SOURCE:  WHO, UNAIDS

## HIV/AIDS cases among IDUs

**No Data Reported**

**0% HIV/AIDS cases among IDUs**

**< 10% HIV/AIDS cases among IDUs**

**10-40% HIV/AIDS cases among IDUs**

**40%+ HIV/AIDS cases among IDUs**

- SOURCE:  WHO, UNAIDS; MOH, Malaysia, 2006

**Malaysia: 76% HIV/AIDS cases related to IDU**

## Malaysia – a case study

- HIV continues to spread among IDUs
- Steady increase in HIV prevalence among IDU in the past 20 years
- HIV transmitted into general population via sexual behaviors of drug users
- 76% of 73,427 HIV-positive cases in Malaysia attributable to IDU (Ministry of Health, Malaysia, June 2006)

## Opiate use in Malaysia

- Heroin and other opiates, (e.g., morphine, opium, buprenorphine) are the dominant drugs of abuse
- High proportion IDU
- >70% report lifetime IDU
- >40% report current IDU
- 275,499 registered heroin users in 2004
- Heroin dependent individuals estimated to exceed 500,000
- Rapid increase in amphetamine-type stimulant (ATS) abuse in recent years

## Drug treatment policy in Malaysia

- Until recently, the Malaysian Narcotic Agency, and not the Ministry of Health, was responsible for dealing with drug abuse and related problems
- Establishing policies, training rehabilitation personnel, etc.
- Drug use, possession of drugs/drug paraphernalia, or testing positive for drugs typically led to enforced internment in residential drug rehabilitation centers
- Several centers continue to operate
- The failure of criminal penalties to prevent drug use and increase in HIV rates resulted in a growing interest to explore medical treatment options, including agonist maintenance
- Methadone opposed on cultural and religious grounds

## Challenges in Malaysia - 2002

- In the context of primarily criminal treatment of drug abuse problems and a rising interest in medical treatments, important to
- Provide “local evidence” of improved efficacy of medication maintenance over detoxification only
- Train addiction specialists, drug counselors, and other medical personnel
- Help expand access to treatment and improve treatment availability
- Challenges addressed by NIDA funded international collaborative grant (PI: R.S. Schottenfeld)
- Established a community-based outpatient research clinic and physician office sites in Muar (~120,000 population)
- To date, Yale and Muar teams completed 1 RCT (N=126) and 2 pilot studies (N=10 and N=26)
- Presently conducting the pilot phase of a second RCT (N=240)

## Research team in Muar, Malaysia

## First RCT in Muar, Malaysia

- Randomized, double-blind, double-dummy clinical trial comparing detoxification followed by drug counseling only, or drug counseling combined with buprenorphine or with naltrexone
- 24 week outpatient drug and HIV risk reduction counseling (all patients)
- Counseling consisted of weekly individual sessions with  a nurse counselor, monthly group sessions with a physician, and additional family sessions as needed
- Each patient (N=126) randomly assigned to
- Thrice weekly buprenorphine maintenance, or
- Thrice weekly naltrexone maintenance, or
- Thrice weekly placebo medication

## Main study outcomes

- Retention

- Time to first heroin use after detoxification

- Time to heroin relapse

- Longest duration of abstinence

- Treatment retention

- Time to heroin relapse after detoxification

## Changes in HIV risk behaviors

- Reductions in drug related risks

- No reductions in sex related risks

## Study impact in Malaysia

- Buprenorphine maintenance treatment first introduced by our study in a research setting
- Subsequent rapid dissemination in general medical care
- Subutex (buprenorphine mono tablets) approved in 2002 for maintenance treatment, including physician office dispensing
- Methadone approved in 2003, including physician office dispensing
- Suboxone (buprenorphine and naloxone combination tablet) approved in 2006, and Subutex withdrawn from the market due to serious diversion and abuse problems including injection use
- ~ 30,000 patients on buprenorphine in private physician offices

## Study implications

- Supports dissemination of buprenorphine (or an agonist) maintenance treatment combined with drug counseling
- Room for improvement
- <50% completed entire treatment and <30% completed without relapse in buprenorphine group
- Consistent with other studies, sexual risks were not reduced by drug treatment

## Current challenges in Malaysia

- Small proportion of patients receive drug counseling or psychotherapy due to the limited number of trained personnel
- Targets of improved drug counseling
- Increase treatment retention
- Reduce drug use and instill lifestyle changes
- Study participants noted beneficial effects of medications (especially, buprenorphine), but did not understand the importance of lifestyle changes in supporting long-term abstinence
- Enhance medication adherence
- Address sexual risks more effectively

## Developing improved counseling

- We have developed an improved integrated drug abuse and HIV risk reduction intervention, Behavioral Drug and HIV Risk Reduction Counseling (BDRC)
- Based on U.S. and International research outcomes, clinical feedback, and focus groups with patients
- Founded on principles of cognitive-behavioral treatments and utilizes evidence based counseling approaches supported by research findings in cognitive and health psychology on effective behavior change
- Designed to be provided by personnel available in resource poor countries, such as nurses, and not by psychologists, psychiatrists, or specialized therapists

## BDRC features

- Educational, directive, and prescriptive
- Uses short-term behavioral contracts aimed at improving treatment adherence and getting patients to make initial lifestyle changes, including
- Cessation of drug use
- Cessation of drug- and sex-related risk behaviors
- Provides immediate feedback and positive reinforcement of patient progress
- Current research shows that positively- or gain-framed health promotion messages increase the likelihood of patient adherence to treatment recommendations and engagement in behavioral change
- Links the initial treatment gains with long-term recovery goals

## BDRC efficacy – pilot study

- 16 week pilot RCT enrolling heroin dependent individuals (N=26) recently conducted in Muar, Malaysia
- All study participants received physician management (PM), consisting of brief, weekly visits with a physician
- Participants in the PM+BDRC group additionally received weekly individual counseling (provided by trained drug counselors)
- Patients in PM group received non-contingent weekly take-home doses of buprenorphine
- Patients in PM+BDRC group received abstinent contingent take-home doses of buprenorphine

## Pilot findings

- Both groups significantly reduced HIV risk behaviors during treatment from pre- treatment baseline

## Feasibility of implementing BDRC

- BDRC is feasible for implementation in resource poor countries
- Our studies demonstrate that medical personnel (nurses) available in resource poor countries can be trained to provide BDRC
- BDRC training to date
- 6 regular drug counselors in pilot studies in the U.S.
- 4 nurses in our current pilot studies in Malaysia provided BDRC; additional >20 nurses and other medical personnel in Malaysia received training in BDRC
- >20 counselors, nurses, or other personnel in several clinics in Thailand and China trained to provide BDRC treatment as a part of HPTN 058 research protocol
- 2 clinicians in Iran provided BDRC in pilot studies

## Conclusions

- Effective treatment and prevention interventions, including a range of counseling approaches, are available
- Country- or region-wide healthcare policy should include a broad spectrum of treatment options including medications and a range of psychosocial interventions
- Research on local dissemination and implementation of effective treatments is critical to reach those most in need

## Acknowledgments

- Richard S. Schottenfeld, M.D.
- Mahmud Mazlan, M.D.
- Clinical and research staff of Substance Abuse Center in Muar, Malaysia
- NIDA