Design and implementation of a factorial randomized controlled trial of methadone maintenance therapy and an evidence-based behavioral intervention for incarcerated people living with HIV and opioid dependence in Malaysia

Abstract

Incarcerated people living with HIV and opioid dependence face enormous challenges to accessing evidence-based treatment during incarceration and after release into the community, placing them at risk of poor HIV treatment outcomes, relapse to opioid use and accompanying HIV transmission risk behaviors. Here we describe in detail the design and implementation of Project Harapan, a prospective clinical trial conducted among people living with HIV and opioid dependence who transitioned from prison to the community in Malaysia from 2010 to 2014. This trial involved 2 interventions: within-prison initiation of methadone maintenance therapy and an evidence-based behavioral intervention adapted to the Malaysian context (the Holistic Health Recovery Program for Malaysia, HHRP-M). Individuals were recruited and received the interventions while incarcerated and were followed for 12months after release to assess post-release HIV transmission risk behaviors and a range of other health-related outcomes. Project Harapan was designed as a fully randomized 2×2 factorial trial where individuals would be allocated in equal proportions to methadone maintenance therapy and HHRP-M, methadone maintenance therapy alone, HHRP-M alone, or control. Partway through study implementation, allocation to methadone maintenance therapy was changed from randomization to participant choice; randomization to HHRP-M continued throughout. We describe the justification for this study; the development and implementation of these interventions; changes to the protocol; and screening, enrollment, treatment receipt, and retention of study participants. Logistical, ethical, and analytic issues associated with the implementation of this study are discussed.

Keywords: HIV; Malaysia; Methadone maintenance therapy; Opioid dependence; Prisoner health.

Figure 1

A. Participant flow diagram, methadone maintenance therapy ▲Methadone assignment change from randomization to participant choice. *Reasons for exclusion not mutually exclusive. **All post randomization withdrawals and deaths occurred shortly after screening and before intervention receipt. B. Participant flow diagram, Holistic Health Recovery Program for Malaysia (HHRP-M) *Reasons for exclusion not mutually exclusive. **All post randomization withdrawals and deaths occurred shortly after screening and before intervention receipt. C. Allocation to methadone, pooled over randomization and treatment choice phases. *All post randomization withdrawals and deaths occurred shortly after screening and before intervention receipt.

Figure 1

A. Participant flow diagram, methadone maintenance therapy ▲Methadone assignment change from randomization to participant choice. *Reasons for exclusion not mutually exclusive. **All post randomization withdrawals and deaths occurred shortly after screening and before intervention receipt. B. Participant flow diagram, Holistic Health Recovery Program for Malaysia (HHRP-M) *Reasons for exclusion not mutually exclusive. **All post randomization withdrawals and deaths occurred shortly after screening and before intervention receipt. C. Allocation to methadone, pooled over randomization and treatment choice phases. *All post randomization withdrawals and deaths occurred shortly after screening and before intervention receipt.

Figure 1

A. Participant flow diagram, methadone maintenance therapy ▲Methadone assignment change from randomization to participant choice. *Reasons for exclusion not mutually exclusive. **All post randomization withdrawals and deaths occurred shortly after screening and before intervention receipt. B. Participant flow diagram, Holistic Health Recovery Program for Malaysia (HHRP-M) *Reasons for exclusion not mutually exclusive. **All post randomization withdrawals and deaths occurred shortly after screening and before intervention receipt. C. Allocation to methadone, pooled over randomization and treatment choice phases. *All post randomization withdrawals and deaths occurred shortly after screening and before intervention receipt.

Figure 2. Retention to behavioral follow-up.

Bars represent the fraction of participants completing an evaluation at different times in the study, from the pre-release interview (PRE), the day of release interview (DOR), to the monthly follow-up interviews (M1 to M12).