Underhill K., Dumont D., Operario D.
American Journal of Public Health: 2014, 104(11), p. 27–53.
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Thorough search for evidence uncovers 37 studies which overall suggest that by tackling sexual and injecting risk behaviours, some interventions protect against HIV in adults with a history of criminal justice involvement. Methadone maintenance emerged as the best established.
Summary People who have been involved with the criminal justice system are at risk of HIV infection due to overlapping risk behaviours such as tattooing, violence, unprotected sex, and injecting drug use. There is a need for HIV prevention and risk-reduction interventions in both prison and community settings to tackle this.
The authors of this paper searched for, and reviewed, studies of interventions to prevent HIV infections among people who have been arrested or convicted for a criminal offence. They found 37 relevant studies published between 2000 and 2014 which reported on a range of outcomes including new HIV infections, new sexually transmitted infections, relapse into criminal behaviour, rates of HIV testing, and engagement in or frequency of risky sexual and injecting behaviours.
This review considers studies of interventions to prevent HIV among people with current or previous involvement with the criminal justice system.
Interventions which target injecting risk behaviours may protect against HIV, as well as improve substance use outcomes.
Two interventions showing promise are methadone maintenance treatment and case management.
This summary focuses on one aspect of the paper, injecting outcomes. 17 studies reported use or frequency of injecting at follow-up. In three of these, the intervention had a significant benefit. Two were trials of methadone maintenance treatment for men in prison, and the other involved case management for people being released into the community after arrest. In study one, men who received methadone maintenance treatment reported a lower use and frequency of heroin or other drug injecting at short-term follow-up, and were less likely to report sharing injecting equipment at medium-term follow-up, compared with controls who received other forms of drug treatment.
In study two, men who received methadone maintenance treatment reported a lower use and frequency of heroin or other drug injecting at short-term follow-up, and were also less likely to report sharing injecting equipment at short-term follow-up compared with people who had to wait for treatment.
In study three, the researchers found that participants who received six months of case management after arrest were less likely to say they had injected drugs compared with those who had just viewed an educational video with or without also being offered a counselling session. However, these effects were not sustained at medium-term follow-up. It also found that those who received case management were less likely to share needles. Also, among those who did share needles, case management recipients were more likely to clean needles before use than those who received the video without counselling. Similar to the results for the frequency of injecting, these effects were not sustained beyond short-term follow-up.
Few studies examined the impact of interventions on new HIV or sexually transmitted infections. Many more looked at the impact of interventions on behaviours that risk HIV infection. The review found some interventions which did have a significant impact on HIV-related risk behaviours, which may have a protective effect on populations at risk of HIV. In line with previous reviews, the findings suggest that opioid substitution therapies (such as methadone maintenance treatment) in prison may reduce drug-related and HIV-related risks. The authors argue that the findings of this review support policy changes to enable a wider variety of HIV prevention efforts.
commentary Despite a search for international literature, the authors found only three studies conducted outside of the United States, and zero conducted within Europe. This does limit generalisability to the UK.
Overall, methadone maintenance treatment and case management may be effective in addressing substance use (and subsequently reducing HIV-related risks) among people with a history of criminal justice involvement. One of the reviewed studies of methadone maintenance treatment, featured in the following Effectiveness Bank commentary, indicates that treatment within prison makes its greatest contribution when it paves the way for continued treatment on release from prison. In the UK context, the main barriers to this include problems arranging housing, waiting lists for community treatment, poor coordination, the lack of specific funding, and short sentences with little time for planning. Case management within substance using populations is a relatively young approach within the UK, only starting to be used from the 1980s onwards. This Effectiveness Bank thematic review considers what models of case management might be effective for improving treatment access and drug-related outcomes for substance using populations.
This draft entry is currently subject to consultation and correction by the study authors and other experts.
Last revised 24 February 2016. First uploaded 15 February 2016
MATRIX CELL 2017 Drug Matrix cell A1: Interventions; Reducing harm
DOCUMENT 2014 Time limiting opioid substitution therapy