Improving access to test results for participants in bio-behavioural surveys of people who inject drugs.

Bio-behavioural surveys of people who inject drugs (PWID) evolved from unlinked anonymous monitoring (UAM) of human immunodeficiency virus (HIV) incidence and prevalence, which began in some high-income countries in the late 1980s. UAM was conducted purely for surveillance purposes and test results were not returned to participants. Later, the importance of collecting data on behavioural risk factors was recognised, leading to the development of bio-behavioural surveys of PWID, which today are conducted regularly in several countries. Typically, these surveys recruit participants from venues providing harm reduction services and involve behavioural questionnaires and dried blood spot (DBS) testing for HIV and hepatitis C (HCV). DBS test results are not returned to participants; instead, countries offer varied systems of on-site testing separate from the bio-behavioural testing or provide referrals to external testing services. In this commentary, we trace the history of bio-behavioural surveys of PWID from their origins to the present day to explain how the methodologies evolved, along with the ethical considerations underlying them. We highlight the dramatic improvements in treatments for HIV and HCV over the past thirty years and the corresponding need to ensure that bio-behavioural survey participants can access low-barrier and timely testing. We review the pros and cons of different strategies for providing test results to participants and argue that the return of DBS results collected as part of bio-behavioural surveys warrants consideration as an additional tool to improve testing access for participants. Any changes should be informed by the perspectives of participants, study site personnel and investigators.

Risk of sexual transmission of HIV in the context of viral load suppression.

Background: In 2018, the Public Health Agency of Canada (PHAC) published a systematic review to calculate the risk of sexual transmission of human immunodeficiency virus (HIV) in the context of antiretroviral therapy (ART). In 2022, PHAC commissioned the Canadian Agency for Drugs and Technologies in Health (CADTH) to conduct a rapid review of evidence published since 2017. We undertook a meta-analysis of relevant studies from these two reviews. Methods: Studies from the rapid review that adequately assessed exposure (HIV viral load) and outcome (HIV seroconversion) were included and assessed for risk of bias (RoB) and certainty of evidence. Results were pooled to estimate the risk of HIV transmission per 100 person-years. Results: Three studies from the rapid review were eligible for inclusion and one was excluded after RoB assessment. In the remaining studies examining risk among people living with HIV who take ART and maintain a suppressed viral load (fewer than 200 copies/mL, measured every 4-6 months), no sexual transmissions of HIV were observed. The pooled incidence estimate based on these studies, and one from the 2018 PHAC review, was zero transmissions/100 person-years (95% CI: 0.00-0.10). No studies in the rapid review provided data on the risk of sexual transmission of HIV in situations of varying levels of viral load. Conclusion: This update highlights the consistency of evidence since the 2018 PHAC review. There remains no evidence of HIV transmission to sexual partners when a person living with HIV is on ART and maintains a suppressed viral load.

Physicians' perspectives on processes for emergency mental health transfers from university health clinics to hospitals in Ontario, Canada: a qualitative analysis.

BACKGROUND: In Ontario, Canada, there is variability in how students experiencing a mental health crisis are transferred from university health clinics to hospital for emergent psychiatric assessment, particularly regarding police involvement and physical restraint use. We sought to understand existing processes for these transfers, and barriers to and facilitators of change. METHODS: Between July 2018 and January 2019, we conducted semistructured qualitative interviews by telephone or in person with physicians working at Ontario university health clinics. We developed the interview guide by integrating an extensive literature review, and the expertise of stakeholders and people with lived experience. We analyzed the interview transcripts thematically. Analysis was informed by participant responses to a questionnaire exploring their perspectives about crisis transfer processes. We requested institutional policy and process documents to support analysis and generate a policy summary. RESULTS: Eleven physicians (9 family physicians and 2 psychiatrists) from 9 university health clinics were interviewed. Ten of the 11 completed questionnaires. Policy and process documents were obtained from 5 clinics. There was variation in processes for emergency mental health transfers and in clinicians' experiences with and beliefs about these processes. Police were commonly involved in transfers from 7 of the 11 clinics, and in nearly all or all transfers from 5 of the 11 clinics. Handcuffs were always or almost always used during transfer at 2 clinics. Three major themes were identified: police involvement and restraint use can cause harm; clinical considerations are used to justify police involvement and restraint use; and pragmatic, nonclinical factors often inform transfer practices. INTERPRETATION: The involvement of police and use of restraints in crisis mental health transfers to hospital were related to pragmatic, extramedical factors in some university health clinics in Ontario. Exploring existing variability and the factors that sustain potentially harmful practices can facilitate standard implementation of less invasive and traumatizing transfer processes.

Policies and procedures for patient transfers from community clinics to emergency departments under the mental health act: Review and policy scan.

OBJECTIVE: The objective of this commentary is to summarize the few findings from the scientific literature pertaining to humane mental health transfer practices in the province of Ontario as well as the broader Canadian and international context. These findings are juxtaposed with a policing policy scan concerning the Ontario and Canadian contexts. The practice of default restraint use during transfers is surprisingly widespread practice, despite advocacy to the contrary, and is presented as the consequence of stigma and the lack of codified restriction of restraint use by police in their policy guidelines. METHODS: (1) Literature search to discover relevant articles which were summarized using narrative review due to the lack of high-quality studies available in this area, and (2) Scan of publicly available policy documents in use by Ontario police agencies in March and April of 2018, as well as contacting several police agencies and community resources to review policies and procedures. RESULTS: We review the available evidence on the use and impact of restraints in patient transfer to emergency departments from police settings, highlight police practices in four Ontario jurisdictions, and summarize recommendations from police and mental health advocates regarding mental health transfers. DISCUSSION: Synthesizing the available evidence, policies, and procedures, we illustrate that the Ontario-wide variability in both who transfers PMI on a Form 1 to hospital and whether restraints are utilized reflect systemic failures to utilize least restrictive means of transfer. We offer a look at future areas of research and advocacy to improve practices in Canada.