Drug Treatment Combined With Drug and Risk Reduction Counseling in the Prevention of HIV Infection and Death Among Injection Drug Users

• Self-report of continued injection opiate use [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Urinalysis results positive for opiates [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Self-reported frequency of injection [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Self-reported frequency of injection with previously used injection equipment (needles, syringes, cookers, cottons, and rinse water) [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Self-reported frequency of unprotected sex or sex sold/traded for drugs [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Self-report of number of days employed in past month [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Self-report of incarceration, detention, and jail [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Self-report of enrollment into drug treatment programs at the 78 and 104 week visits [ Time Frame: Measured at Weeks 78 and 104 ] [ Designated as safety issue: No ]
• Incident hepatitis C infections [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Incident hepatitis B infections [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Incidence of HIV infections [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Death [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• ALT toxicity grades [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Bilirubin toxicity grades [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• ALT lab values [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Bilirubin lab values [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]
• Study site confirmed report of incarceration, detention, and jail [ Time Frame: Measured through Week 156 ] [ Designated as safety issue: No ]

• HIV-1 infection every 6 months at scheduled study follow-up visits
• mortality
• continued opiate use as measured by self-report and urinalysis
• self-reported frequency of injection
• self-reported frequency of injection with previously used injection equipment (needles, syringes, cookers, cottons, and rinse water)
• self-reported frequency of unprotected sex or sex sold/traded for drugs

Drug abuse and HIV/AIDS are serious global health problems. Injection drug use is currently the major mode of transmission of HIV in many countries. The purpose of this study is to determine the effectiveness of drug and risk reduction counseling combined with either substitution drug treatment with buprenorphine/naloxone (BUP/NX) or short-term detoxification with BUP/NX in preventing HIV transmission among injection drug users. Participants will be recruited for this study in China and Thailand.

Effective HIV prevention among injection drug users (IDUs) requires educating the at-risk population about HIV transmission and risky behavior, and providing the means for behavior change. Current treatment for opiate dependence focuses on reducing the frequency of drug use. BUP/NX is a combination pill currently used to treat opiate-dependent individuals. This trial will evaluate the effectiveness of two therapies in preventing HIV transmission among IDUs. Drug and risk reduction counseling combined with either long term medication assisted treatment (LT-MAT) with BUP/NX or short term medication assisted treatment (ST-MAT) with BUP/NX will be compared in preventing the transmission of HIV among opiate-dependent individuals.

This study will last 4.5 years. Participants in this study will be randomly assigned to one of two treatment arms. Group 1 will receive LT-MAT with BUP/NX. Group 2 will receive ST-MAT with BUP/NX. An initial 4-week safety and feasibility phase will involve the first 50 participants at each site and will last approximately 30 weeks. Study visits will occur every week and will include a physical exam and blood and urine collection.

The main treatment phase of the study will last 52 weeks. Participants in Group 1 will receive BUP/NX under the tongue, at first daily and then three times a week for 52 weeks. Participants assigned to Group 1 will take part in a BUP/NX reduction phase, which will occur between Weeks 47 and 52. Participants in Group 2 will receive short-term BUP/NX; dosage and length of treatment will be determined by the investigator. Participants assigned to Group 2 will receive BUP/NX for a maximum of 18 days; detoxification may be repeated at Week 26 if the participant is still injecting opiates. After Week 4 of the safety phase and Weeks 26 and 52 of the overall study, participants will complete an intervention acceptability assessment.

In addition, participants in both groups will attend drug and risk reduction counseling weekly. After the first 12 weeks, participants will return every 4 weeks for 10 more counseling sessions. HIV testing, hepatitis C testing, risk assessment, and urine tests for opiates will occur at screening and at Weeks 26, 52, 78, 104, 130 and 156. Plasma from blood samples will be stored at each of these visits. Hepatitis B testing will occur at Week 26. Participants in China will attend study visits through approximately Week 104, and participants in Thailand will attend study visits through approximately Week 156.

Participants in China who have been incarcerated may participate in an optional substudy, which is examining the withdrawal effects from BUP/NX after incarceration. Participants who agree to take part in the substudy will attend one study visit and will complete a questionnaire.

• HIV Infections
• Opioid-Related Disorders

• Experimental: Long term medication assisted treatment (LT-MAT)
  Participants will receive BUP/NX under the tongue daily for a maximum of three weeks(until dose stabilization) and then three times a week for 52 weeks in addition to weekly drug and risk reduction counseling for 12 weeks, and then every 4 weeks through Week 52
  Intervention: Drug: Buprenorphine/Naloxone
• Experimental: Short term medication assisted treatment (ST-MAT)
  Participants will receive short-term BUP/NX; dosage and length of treatment will be determined by the investigator.Additionally, participants will undergo weekly drug and risk reduction counseling for 12 weeks, and then every 4 weeks through Week 52.
  Intervention: Drug: Buprenorphine/Naloxone

• Aceijas C, Stimson GV, Hickman M, Rhodes T; United Nations Reference Group on HIV/AIDS Prevention and Care among IDU in Developing and Transitional Countries. Global overview of injecting drug use and HIV infection among injecting drug users. AIDS. 2004 Nov 19;18(17):2295-303.
• Gowing L, Farrell M, Bornemann R, Ali R. Substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004145. Review.
• Koester S, Glanz J, Baron A. Drug sharing among heroin networks: implications for HIV and hepatitis B and C prevention. AIDS Behav. 2005 Mar;9(1):27-39.
• Raisch DW, Fye CL, Boardman KD, Sather MR. Opioid dependence treatment, including buprenorphine/naloxone. Ann Pharmacother. 2002 Feb;36(2):312-21. Review.
• Ruan Y, Qin G, Liu S, Qian H, Zhang L, Zhou F, He Y, Chen K, Yin L, Chen X, Hao Q, Xing H, Song Y, Wang Y, Hong K, Chen J, Shao Y. HIV incidence and factors contributed to retention in a 12-month follow-up study of injection drug users in Sichuan Province, China. J Acquir Immune Defic Syndr. 2005 Aug 1;39(4):459-63.
• Lucas GM, Beauchamp G, Aramrattana A, Shao Y, Liu W, Fu L, Jackson JB, Celentano DD, Richardson P, Metzger D; HPTN 058 study group. Short-term safety of buprenorphine/naloxone in HIV-seronegative opioid-dependent Chinese and Thai drug injectors enrolled in HIV Prevention Trials Network 058. Int J Drug Policy. 2012 Mar;23(2):162-5. Epub 2011 Aug 17.
• Sugarman J, Corneli A, Donnell D, Liu TY, Rose S, Celentano D, Jackson B, Aramrattana A, Wei L, Shao Y, Liping F, Baoling R, Dye B, Metzger D. Are there adverse consequences of quizzing during informed consent for HIV research? J Med Ethics. 2011 Nov;37(11):693-7. Epub 2011 Jun 8.

Inclusion Criteria:

• HIV-uninfected within 28 days of enrollment
• Meets DSM-IV criteria for opiate dependence
• Positive urine test for opiates
• Injected opiates at least 12 times in the 28 days prior to enrollment, according to self-report
• Willing to use acceptable forms of contraception for the first 12 months of the study
• Able to provide contact information and willing to be contacted by study staff as necessary
• Available for study visits for at least 2 years

Exclusion Criteria:

• Current treatment with methadone, morphine, levo-alpha-acetyl-methadol (LAAM), naltrexone, or nalmefene
• Currently enrolled in another HIV prevention or drug use intervention study
• Known sensitivity to buprenorphine or naloxone
• Requires immediate medical attention for dependence on alcohol, benzodiazepines, or other substances. People who are dependent on tobacco are not excluded.
• Currently injecting drugs of abuse other than opiates, more than twice in the last 28 days, according to self-report
• Psychological disturbance or cognitive impairment that may interfere with the study
• Acute or chronic kidney failure
• Certain abnormal laboratory values
• Any other medical or psychiatric condition that, in the opinion of the investigator, would make participation in this study unsafe
• Pregnant or breastfeeding

Inclusion Criteria for Substudy:

• Current or former participant in HPTN 058 study in Xinjiang who was actively in the long-term treatment arm on stable maintenance dose of Suboxone when detained/arrested (last dose within 2 days of incarceration), resulting in immediate cessation of Suboxone without tapering
• Currently released from detention
• Willing to complete one-time questionnaire
• Willing to sign informed consent

Exclusion Criteria for Substudy:

• Any medical or psychiatric condition that, in the opinion of the investigator, would make participation in the study unsafe, or would otherwise interfere with the study objectives or interpretation