HIV prevention: A 3-pronged approach

Harm reduction is a collection of strategies meant to reduce complications of illicit drug use, including HIV transmission. These strategies include needle and syringe programs that provide injection drug users with sterile equipment, and opioid substitution therapy.

Needle and syringe programs decrease HIV transmission⁴⁹ and risky behaviors related to injection drug use,⁵⁰ but federal funding of such programs is prohibited. Opioid substitution therapy reduces the incidence of HIV,^50,51 injection drug use, sharing of drug preparation and injection equipment, and drug-related behaviors associated with a high risk of HIV transmission.^50,52 However, in the United States, the quality of these programs varies; a study of opioid substitution therapy delivery found that 22.8% of programs provided doses that were too low to be effective.⁵³

In clinical trials of pre-exposure prophylaxis, drug resistance has been rare and mostly limited to those who had unrecognized acute HIV infection.

FDA-approved medications for opioid substitution therapy include sublingual buprenorphine, sublingual buprenorphine/naloxone tablets or strips (Suboxone), and oral methadone. Buprenorphine-based regimens can be provided by appropriately trained primary care clinicians; methadone requires a referral to a narcotic treatment program. TABLE 4 provides training and support resources for physicians who want to integrate opioid substitution therapy into their clinical practice.

CORRESPONDENCE
Richard Moore II, MD, 250 Smith Church Road, Roanoke Rapids, NC 27870; moorera2@gmail.com.