Background-Directly observed therapy (DOT) programs for HIV treatment have demonstrated feasibility, acceptability, and improved viral suppression, but few have been rigorously tested. We describe a randomized controlled trial testing the efficacy of an antiretroviral DOT program in methadone maintenance clinics. Our objective was to determine if DOT is more efficacious than self-administered antiretroviral therapy for reducing HIV viral load, improving adherence, and reducing drug resistance among opioid dependent drug users receiving methadone treatment.

Background Heroin abusing patients present a significant challenge. Objective Structured Clinical Exams (OSCEs) allow evaluation of residents’ clinical skills. The objective of our study was to examine resident OSCE performance assessing and managing heroin abuse. Methods Evaluation and comparison of heroin-specific communication, assessment and management skills in a five-station PGY3 substance abuse OSCE. Faculty used a four-point Likert scale to assess residents’ skills; standardized patients provided written comments. Results 265 internal and family medicine residents in an urban university hospital participated over five years. In the heroin station, residents’ skills were better (p<0.001 for both comparisons) in communication (mean overall score 3.16±0.51) than in either assessment (mean overall score 2.66±0.60) or management (mean overall score 2.50±0.73). The mean score for assessing specific high risk behaviors was lower than the mean overall assessment score (2.22±1.01 vs. 2.74±.59, p < 0.0001), and the mean score for recommending appropriate harm reduction management strategies was lower than the mean overall management score (2.39±.89 vs. 2.54±.74, p < 0.005). Standardized patients’ comments reflected similar weaknessess in residents’ skills. Conclusions Assessment and management of heroin abuse were more challenging for residents than general communication. Additional training is required for residents to assess and counsel patients about high risk behaviors.

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