Authors' objectives

To evaluate the effectiveness of interventions with United States drug users (injection and non-injection) to reduce their sexual risk for human immunodeficiency virus (HIV) infection.

Searching

The HIV/AIDS Prevention Research Synthesis (PRS) database (see Other Publications of Related Interest) was searched for studies that were reported by 1998 (the database includes studies reported from 1988 onwards). This database is based on searches of 8 electronic databases (AIDSLINE, CINAHL, DAI, ERIC, HealthSTAR, MEDLINE, PsycLIT and Sociofile), handsearches of 53 journals, conference proceedings, reference lists, and contact with researchers and agencies working in the field.

Study selection

Assessment of study quality

The authors do not state that they assessed quality, although methodological criteria were used to include or exclude studies from the PRS database.

Data extraction

The data extraction was carried out in duplicate and a procedure was in place for identifying and resolving discrepancies (method unspecified). The first follow-up data for sexual risk reduction was used from studies where there was repeated follow-up. An overall behavioural outcome that consisted of reducing unprotected sex or increasing the use of male condoms (a hierarchy of preference was used for studies reporting both outcomes) was extracted. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for individual studies.

Methods of synthesis

Results of the review

Thirty-three studies were included: 31 experimental and 2 quasi-experimental.

Drug users receiving a HIV prevention intervention (33 studies) were more likely to reduce their sexual risk behaviours than the comparison group: OR 0.86 (95% CI: 0.76, 0.98). Statistical heterogeneity was found (Q=59.17, p=0.002).

In the stratification analysis, there was a stronger protective effect for the intervention group in studies where the control group did not receive an intervention (3 studies) compared with studies where the comparison group received an HIV prevention intervention (30 studies); the ORs were 0.60 (95% CI: 0.43, 0.85) and 0.91 (95% CI: 0.81, 1.03), respectively. Statistical heterogeneity was again found.

Further subgroup analyses of the studies where the comparison group also received an intervention found a statistically-significant effect for studies where the participants used crack in addition to injecting drugs (24 studies) compared with studies where only injecting drugs were used (6 studies); the ORs were 0.88 (95% CI: 0.77, 1.00) and 1.05 (95% CI: 0.76, 1.44), respectively.

Authors' conclusions

The interventions can lead to meaningful sexual risk reduction among drug users; this justifies providing interventions to drug users.

CRD commentary

The review question was clear in terms of the intervention, participants, study design and outcomes. However, the eligibility criteria for the participants was very broad, therefore participants other than those at primary risk for HIV through drug use may have been included. A number of relevant electronic databases were searched and unpublished data were sought. The data extraction was carried out in duplicate, which helps to minimise errors and bias, though details of other review processes were not reported. Although the studies were required to meet specified methodological criteria for entry into the database from which the studies were selected, a quality assessment was not reported. There was also limited discussion of the results in the context of study quality.

The details of the individual studies were not reported, therefore it was not possible to assess possible sources of heterogeneity between the studies. Given the evidence of heterogeneity, it is unlikely that it was appropriate to pool the data. Possible sources of heterogeneity were investigated, though this was limited by the data available to the authors. The pooled estimates may be imprecise given the inappropriate pooling of the studies and the unexplained heterogeneity. In addition, the applicability to other settings is unclear since only U.S. studies were included.

Implications of the review for practice and research

Practice: The authors state that the findings justify providing interventions to drug users. They note, however, that although providing interventions is superior to not providing an intervention to reduce sexual risk behaviours, there is no basis for determining the most effective form of intervention.

Research: The authors state that where interventions are provided to both the intervention and comparison groups, there needs to be a meaningful difference between the two interventions. Studies are required to examine the characteristics of effective interventions. The authors also highlight the need for additional research in relation to injection drug users who also use crack. Consensus is also required on the most appropriate sexual risk outcome measure to use. Finally, more complete reporting of data in publications is needed.

Bibliographic details

Semaan S, Des Jarlais D C, Sogolow E, Johnson W D, Hedges L V, Ramirez G, Flores S A, Norman L, Sweat M D, Needle R. A meta-analysis of the effect of HIV prevention interventions on the sex behaviors of drug users in the United States. Journal of Acquired Immune Deficiency Syndromes 2002; 30(Supplement 1): S73-S93. [PubMed: 12107362]

Other publications of related interest

Sogolow E, Peersman G, Semaan S, Strouse D, Lyles CM.. The HIV/AIDS Prevention Research (PRS) Project: scope, methods and initial findings. J Acquir Immune Defic Syndr 2002;30 Suppl 1:S15-S29.

Indexing Status

Subject indexing assigned by NLM

MeSH

Acquired Immunodeficiency Syndrome /prevention & control; Adult; Behavior Therapy /methods /standards; Condoms; Female; Humans; Male; Risk-Taking; Safe Sex; Sexual Behavior; Substance-Related Disorders; United States

AccessionNumber

12002001769

Database entry date

30/11/2003

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.