Photo elicitation to explore health and social exclusion with rooming house residents in Ottawa, Canada.

Little is known about how rooming house residents perceive how housing influences their health, despite higher morbidity and premature death compared to other Canadians. The social exclusion framework of the Social Knowledge Exchange Network (SEKN) conceptualized by Popay et al. (2008) was used to investigate how rooming houses are linked to health among ten rooming house residents from six rooming houses in Ottawa, Ontario, Canada. Study activities included taking photos to show how living in a rooming house affects health, a community walk-about with the principal investigator, a focus group, and individual interviews. Thematic analysis revealed two broad themes: Housing is Health Care, and Just Managing Today. Findings suggest that structural inequalities and siloed care contribute to the health of rooming house residents, including the balance between poverty and desire to maintain housing, and how residents cope with this stress. If health care providers want to help alleviate the disparities in rooming house residents' health, they need to broaden the lens through which health is conceptualized.

"They're all struggling as well": social and economic barriers and facilitators to self-managing chronic illness among marginalized people who use drugs.

PURPOSE: Self-management is recommended for addressing chronic conditions, and self-management programmes improve health behaviours and outcomes. However, social and economic factors have been neglected in self-management research, despite their relevance for marginalized groups. Thus, we aimed to explore barriers and facilitators that influence self-management among socioeconomically marginalized people who use drugs (PWUD). METHODS: Using community-based participatory methods, we developed a qualitative interview guide and conducted peer-led recruitment. Participants were admitted into the study after self-identifying as using non-prescribed drugs, having a chronic health issue, and experiencing socioeconomic marginalization. Data were analysed using reflexive thematic analysis, taking a relational autonomy lens. RESULTS: Participants highlighted substantial barriers to managing their health issues, mostly stemming from their social and economic environments, such as unstable housing, low income, lack of supportive social networks, and negative healthcare experiences. Participants also described how their ability to self-manage their chronic conditions benefited from specific aspects of social interactions, including close relationships, community connectedness, and engaging in peer support. CONCLUSIONS: Our findings suggest that structural interventions are needed to support self-management among marginalized PWUD, especially stable housing. Self-management supports for PWUD would benefit from including a range of low-barrier community-based options, peer work opportunities, and advocacy for needs.

"The Drug Use Unfortunately isn't all Bad": Chronic Disease Self-Management Complexity and Strategy Among Marginalized People Who Use Drugs.

Self-management programs improve health outcomes and self-management is recommended for chronic conditions. Yet chronic disease self-management supports have rarely been applied to people who use drugs (PWUD). Thus, our objective was to explore self-management experiences among marginalized PWUD. We used community-based participatory methods and conducted qualitative interviews. Participants self-identified as having long-term and past year experience using non-prescribed drugs, one other chronic condition, and socioeconomic marginalization. We analyzed the data using reflexive thematic analysis. Although many participants considered drug use a chronic health issue, self-medicating with non-prescribed drugs was also a key self-management strategy to address other health issues. Participants also described numerous other strategies, including cognitive and behavioral tactics. These findings highlight the need for a safe supply of pharmaceutical-grade drugs to support self-management among marginalized PWUD. Self-management supports should also be tailored to address relevant topics (e.g., harm reduction, withdrawal), include creative activities, and not hinder PWUD's agency.

The Urgent Need to Respond to HIV- and HCV-Related Risk Practices among Youth in Ottawa Who Smoke Crack.

BACKGROUND: A community-based research project, Project Rock sought to provide evidence to respond to the community-identified need to more fully understand the parameters of the social and risk profiles of youth in Ottawa who smoked crack. Objectives: In this article we examine engagement in HIV and HCV risk-related smoking practices, and experiences accessing safer inhalation supplies with the objective of identifying potential intervention points and associated harm reduction interventions to initiate and support safer inhalation practices. Methods: The study comprised four sequential components - formation and facilitation of a Youth Project team, qualitative interviews, and member checking workshops - each component building on the preceding and all contributing to the final and fourth component of the interviewer-administered quantitative survey from which data for this article are drawn. Eligibility criteria: capable of informed consent; aged between 16 and 25 years; had ever injected drugs or had ever tried crack or had used two or more hard drugs in the three months preceding their interview. Recruitment cards distributed by community agencies, honoraria and debriefing offered. Separate consent obtained for collection of finger prick blood samples for HIV and HCV laboratory testing. Results: 125 young people completed personal interviews in November 2013. This article is restricted to those 97 participants who had smoked crack. High rates of engagement in documented HIV- and HCV-related crack smoking practices were reported including nonuse of mouthpieces, use of non-recommended smoking devices and frequent engagement in equipment sharing; engagement compounded by the heightened confirmed prevalence of HCV. Conclusion: The youth in our study explained the utility of crack in their lives. Given the mental health drivers of engagement, ease of accessibility and availability, engagement in smoking crack is clearly likely to continue, firmly indicating the urgent necessity to ensure its safer use through gender neutral, youth-specific enhanced programming and resource distribution.

Increasing the Offer, Shifting the Offer: Patients' Perspectives on Routinely Offering HIV Counseling and POC Testing in the Health Services Program of an Urban Community Health Centre.

Objectives: Canadian epidemiologic data demonstrate the fallibility of established HIV testing approaches to reach, diagnose, and link to care a significant portion of the population thereby contributing to missed opportunities to reduce onward HIV transmission. Increasing and diversifying entry points to accessing HIV testing may be a successful strategy to reach people who remain undiagnosed. We sought to determine the perspectives of patients on the acceptability of an offer of routine non-targeted provider-initiated HIV counseling and point-of-care (POC) testing in the health services program of a Community Health Centre in downtown Ottawa, the capital of Canada. Methods: Patients aged 18 years and over accessing the Health Services Program for scheduled clinical appointments were approached by research staff with the offer of a POC HIV test with pre- and post-test counseling. All patients accepting the offer and those declining the offer were offered the opportunity to complete an Acceptability Questionnaire. Results: Questionnaire responses from eligible patients over four consecutive weeks in 2018 strongly endorse the acceptability of an offer of an HIV test in the context of their scheduled health services appointment for a separate clinical condition. This contention held both for those patients accepting the offer and proceeding to testing and for those patients declining the offer. Conclusions: The perspectives of the patients in our study demonstrate that a routine offer of non-targeted provider-initiated HIV counseling and POC testing was considered not only to be an acceptable, but also an appropriate and welcome intervention in a community health services program. These results suggest the potential for actively engaging more individuals-including those less likely to be engaged through a targeted testing approach-in the documented benefits of the HIV care and treatment cascade by increasing the HIV test offer through routine provider initiation. In addition, at the population level, shifting the offer through venue diversification, similarly shows potential for reducing engagement in ongoing HIV transmission behaviors and practices attributed to those unaware of their HIV positive status. Both outcomes fundamental to the goal of eliminating AIDS by 2030.

Telemedicine successfully engages marginalized rural hepatitis C patients in curative care.

Background: Rurally located individuals living with hepatitis C virus (HCV) face barriers to engagement and retention in care. Telemedicine technologies coupled with highly curative direct acting antiviral (DAA) treatments may increase accessibility to HCV care while achieving high sustained virologic response (SVR) rates. We compared clinical and socio-economic characteristics, SVR, and loss to follow-up among telemedicine (TM), mixed delivery (MD), and outpatient clinic (OPC) patients receiving care through The Ottawa Hospital Viral Hepatitis Program (TOHVHP). Methods: TOHVHP clinical database was used to evaluate patients engaging HCV care between January 1, 2012, and December 31, 2016. SVR rates by HCV care delivery method (TM versus OPC versus MD) were calculated. Results: Analysis included 1,454 patients who engaged with TOHVHP at least once. Patients were aged almost 50 years on average and were predominately male and Caucasian. A greater proportion of TM patients were rurally based, were Indigenous, had a history of substance use, and had previously been incarcerated. Per-protocol DAA SVR rates for TM, OPC, and MD patients were 100% (26/26), 93% (440/472), and 94% (44/47), respectively. Loss-to-follow-up rates for HCV-treated TM and MD patients were higher (27% [10/37], 95% CI 0.58 to 0.88, and 11% [7/62], 95% CI 0.81 to 0.97, respectively) than for those followed exclusively in the OPC (5% [39/800], 95% CI 0.94 to 0.97). Conclusions: TM can successfully engage, retain, and cure rurally based HCV patients facing barriers to care. Strategies to improve TM retention of patients initiating HCV antiviral treatment are key to optimizing the impact of this model of care.

Historique: Les personnes atteintes du virus de l'hépatite C (VHC) qui habitent en milieu rural affrontent des obstacles à l'obtention et à la rétention des soins. Les technologies de télémédecine, couplées à des traitements antiviraux à action directe (AAD) hautement curatifs, peuvent accroître l'accessibilité aux soins du VHC tout en obtenant des taux élevés de réponse virologique soutenue (RVS). Les auteurs ont comparé les caractéristiques cliniques et socioéconomiques, la RVS et la perte au suivi des patients en télémédecine (TM), en prestation mixte (PM) et en clinique ambulatoire (CA) suivis par le Programme de lutte contre l'hépatite virale de l'Hôpital d'Ottawa (PLHVHO). Méthodologie: Les chercheurs ont utilisé la base de données clinique du PLHVHO pour évaluer les patients qui ont participé aux soins du VHC entre le 1er janvier 2012 et le 31 décembre 2016. Ils ont calculé le taux de RVS en fonction de la méthode de prestation des soins du VHC (TM, CA ou PM). Résultats: L'analyse incluait 1 454 patients qui ont participé au moins une fois au PLHVHO. Les patients, âgés en moyenne de près de 50 ans, étaient majoritairement blancs et de sexe masculin. Une plus forte proportion de patients en TM habitait en milieu rural, était d'origine autochtone, avait déjà consommé des substances psychoactives et avait déjà été détenue. Le taux de RVS aux AAD chez les patients en TM, en CA et en PM s'élevait à 100 % (26 sur 26), à 93 % (440 sur 472) et à 94 % (44 sur 47), respectivement. Le taux de perte au suivi des patients atteints du VHC était plus élevé en TM et en PM (27 % [dix sur 37], IC à 95 %, 0,58 à 0,88, et 11 % [sept sur 62], IC à 95 %, 0,81 à 0,97, respectivement) que chez ceux qui étaient suivis exclusivement en CA (5 % [39 sur 800], IC à 95 %, 0,94 à 0,97). Conclusions: La TM peut réussir à faire participer, retenir et guérir les patients atteints d'un VHC qui habitent en milieu rural et affrontent des obstacles à l'obtention des soins. Il est essentiel d'établir des stratégies pour améliorer la rétention des patients en TM qui entreprennent un traitement antiviral contre le VHC pour optimiser les répercussions de ce modèle de soins.

Human immunodeficiency virus testing and psychosocial outcomes: a scoping review protocol.

OBJECTIVE: The proposed scoping review will identify psychosocial outcomes immediately following human immunodeficiency virus (HIV) testing and their measurements, specifically among individuals with a new negative or positive test result. INTRODUCTION: No systematic study has described psychosocial outcomes and their measurements in persons immediately following HIV testing. Also, to our knowledge, there is no consensus on a core set of psychosocial outcomes and measurements following HIV diagnosis, which are essential for quality improvement. INCLUSION CRITERIA: All study designs will be considered. Participants with a new positive or negative HIV test result, regardless of sex or age, in any setting will be included. Any measured beneficial or harmful outcomes in the mental and social domains following a new diagnosis will be included. Psychosocial outcomes of participants undergoing treatment and care will be excluded. METHODS: The databases Ovid MEDLINE, Embase and PsycINFO will be searched, and published articles in English from 2007 to the present date will be included. The methods for scoping reviews outlined by the Joanna Briggs Institute will be followed. Data will be extracted from included studies by two reviewers. Any disagreements between the two reviewers will be solved through discussion in a team of five members. To define the specific concepts or outcome (sub)-domains and their measurements, the models proposed by the Outcome Measures in Rheumatology initiative and the Core Outcome Measures in Effectiveness Trials initiative, respectively, will be used. To analyze the data, this study will rely on a multi-level social-ecological model.

Support of supervised injection facilities by emergency physicians in Canada.

BACKGROUND: Despite evidence supporting the implementation of supervised injection facilities (SIFs) by multiple stakeholders, no evaluation of emergency physicians' attitudes has ever been documented towards such facilities in Canada or internationally. The primary goal of our study was to determine the opinions and perceptions of emergency physicians regarding the implementation of SIFs in Canada. METHODS: We conducted a national electronic survey of staff and resident emergency physicians in Canada using an iteratively designed survey tool in consultation with content experts. Invitations to complete the survey were sent via email by the Canadian Association of Emergency Physicians. Inclusion criteria required respondents to have treated an adult patient in a Canadian emergency department within the preceding 6 months. The primary measure was the proportion of respondents who would support, not support or were unsure of supporting SIFs in their community with the secondary measure being the likelihood of respondents to refer patients to a SIF if available. RESULTS: We received 280 responses out of 1353 eligible physicians (20.7%), with the analysis conducted on 250 responses that met inclusion criteria (18.5%). The majority of respondents stated they would support the implementation of SIFs in their community (N=172; 74.5%) while 10.8% (N=25) would not and 14.7% (N=34) did not know. The majority of respondents said they would refer their patients to SIFs (N=198; 84.6%), with 4.3% (N=10) who would not and 11.1% (N=26) who were unsure. CONCLUSION: The findings from our study demonstrate that the majority of emergency physician respondents in Canada support the implementation of such sites (74.5%) while 84.6% of respondents would refer patients from the emergency department to such sites if they did exist. Given that many Canadian cities are actively pursuing the creation of SIFs or imminently opening such sites, it appears that our sample population of emergency physicians would both support this approach and would utilize such facilities in an effort to improve patient-centered outcomes for this often marginalized population.

Next generation sequencing of the hepatitis C virus NS5B gene reveals potential novel S282 drug resistance mutations.

Identifying HCV drug resistance mutations (DRMs) is increasingly important as new direct acting antiviral therapies (DAA) become available. Tagged pooled pyrosequencing (TPP) was originally developed as cost-effective approach for detecting low abundance HIV DRMs. Using 127 HCV-positive samples from a Canadian injection drug user cohort, we demonstrated the suitability and efficiency of TPP for evaluating DRMs in HCV NS5B gene. At a mutation identification threshold of 1%, no nucleoside inhibitor DRMs were detected among these DAA naïve subjects. Clinical NS5B resistance to non-nucleoside inhibitors and interferon/ribavirin was predicted to be low within this cohort. S282T mutation, the primary mutation selected by sofosbuvir in vitro, was not identified while S282G/C/R variants were detected in 9 subjects. Further characterization on these new S282 variants using in silico molecular modeling implied their potential association with resistance. Combining TPP with in silico analysis detects NS5B polymorphisms that may explain differences in treatment outcomes.

Factors responsible for mother-to-child HIV transmission in Ontario, Canada, 1996-2008.

OBJECTIVE: Despite a high uptake of HIV screening and anti-retroviral prophylaxis in Ontario, several cases of mother-to-child (MTC) transmission occur every year. We wished to examine the modifiable factors responsible for MTC HIV transmission in Ontario, in particular HIV testing, antiretroviral prophylaxis and breast-feeding. METHODS: Using the Ontario data from the Canadian Perinatal HIV Surveillance Program, we examined potential correlates of late maternal HIV diagnosis (i.e., diagnosed at or after delivery) among women delivering from 1996 to 2008. To better understand the factors responsible for MTC HIV transmission, we reviewed the medical charts of 35 HIV-infected infants born in Ontario. RESULTS: Among the 645 HIV-infected mothers, 85 (13.2%) had late HIV diagnosis. The proportion with late HIV diagnosis significantly decreased during the study period, but did not differ by race/ethnicity group or maternal exposure category. With respect to the mothers of the 35 HIV-infected infants, 27 (77%) were diagnosed with HIV at or after delivery. The reasons no prenatal HIV test was performed were: not offered, offered but refused, no prenatal care, denied HIV testing history, and offered but not done. Reasons for no or incomplete antiretroviral  prophylaxis (ARP) among eight mothers diagnosed prior to or during pregnancy were: refused or non-compliant with ARP, and failed to inform care provider of HIV status. CONCLUSIONS: Despite the recommendation for universal prenatal HIV counseling and voluntary testing adopted in Ontario, MTC transmission continued to occur, mostly due to late HIV diagnosis of the mother. Future work to reduce perinatal HIV infection should focus on enhancing timely HIV testing of pregnant women.

Transmission patterns of HIV and hepatitis C virus among networks of people who inject drugs.

BACKGROUND: The risk-related behaviours and practices associated with injection drug use remain a driver of HIV and hepatitis C virus (HCV) transmission throughout the world. Here we evaluated HIV and HCV transmission patterns in the context of social networks of injection drug users (IDU) recruited from a higher incidence region in order to better understand factors that contribute to ongoing transmission among IDU. METHODS: IDU recruited through a chain-referral method provided biological specimens for analysis. HIV and HCV positive specimens were sequenced and analyzed using phylogenetic methods (Neighbour-joining and bayesian) and transmission patterns of HIV and HCV evaluated in the context of the recruitment networks. RESULTS: Among the 407 recruited IDU, HCV and HIV prevalence were 60.6% and 10.1%, respectively; 98% of HIV positive individuals were co-infected with HCV. Thirty-six percent of HCV sequences were associated with clusters, compared to 67% of HIV sequences. Four (16.7%) of the 24 HCV clusters contained membership separated by 2 or fewer recruitment cycles, compared to 10 (41.6%) derived from more than one recruitment component. Two (28.6%) of the 7 HIV clusters contained membership separated by 2 or fewer recruitment cycles while 6 (85.7%) were composed of inter component membership. CONCLUSIONS: Few HIV and HCV transmissions coincided with the recruitment networks, suggesting that they occurred in a different social context or a context not captured by the recruitment network. However, among the complete cohort, a higher degree of HIV clustering indicates many are recent infections originating from within current social networks, whereas a larger proportion of HCV infections may have occurred earlier in injecting history and in the context of a different social environment.

Guidelines for better harm reduction: evaluating implementation of best practice recommendations for needle and syringe programs (NSPs).

BACKGROUND: The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations. METHODS: An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document. RESULTS: The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%, n=28) and satellite NSPs (84%, n=52) distributed cookers following the dissemination of the document. All core NSPs (100%, n=32) and nearly all satellite NSPs (97%, n=60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%, n=27) distributed glass stems than the core NSPs (16%, n=5). Commonly cited implementation barriers included funding, senior management and decision-making. CONCLUSION: Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.

Readiness to shop for low-fat foods: a population study.

BACKGROUND: Stages of change are related to dietary fat consumption. Few studies have examined stage occupation within the context of purchasing low-fat foods. OBJECTIVE: To determine the stage-prevalence of individuals for purchasing low-fat foods; identify the frequency of misclassification into action and maintenance (A/M) stages for purchasing for low-fat foods; and explain the demographic and cognitive-variable differences between pseudo (or false positive) A/M and true A/M individuals. DESIGN: Data were collected using a self-administered questionnaire among English-speaking adults (n=1,001) who were randomly sampled by mail. STATISTICAL ANALYSES PERFORMED: Descriptive statistics were used to compare the characteristics of the stage groups. Groups were compared using chi(2) tests and Student t test. RESULTS: Of those who reported being in A/M stages, 32% were misclassified by the staging algorithm and were not true A/M low-fat food purchasers. CONCLUSIONS: Individuals who are in A/M stages for buying low-fat foods still purchase high-fat foods. Stage misclassification may be a persistent problem in studies of dietary change using the Transtheoretical Model.

"I inject less as I have easier access to pipes": injecting, and sharing of crack-smoking materials, decline as safer crack-smoking resources are distributed.

Among injection drug users (IDUs) in Ottawa, the capital of Canada, prevalence rates of HIV (20.6 percent) and hepatitis C HCV (75.8 percent) are among the highest in Canada. Recent research evidence suggests the potential for HCV and HIV transmission through the multi-person use of crack-smoking implements. On the basis of this scientific evidence, in April 2005, Ottawa's needle exchange programme (NEP) commenced distributing glass stems, rubber mouthpieces, brass screens, chopsticks, lip balm and chewing gum to reduce the harms associated with smoking crack. This study aims to evaluate the impact of this initiative on a variety of HCV- and HIV-related risk practices. Active, street-recruited IDUs who also smoked crack consented to personal interviews and provided saliva samples for HCV and HIV testing at four time points: 6-months pre-implementation (N=112), 1-month (N=114), 6-months (N=157) and 12-months (N=167) post-implementation. Descriptive and univariate analyses were completed. Following implementation of the initiative, a significant decrease in injecting was observed. Pre-implementation, 96 percent of IDUs reported injecting in the month prior to the interview compared with 84 percent in the 1-month, and 78 percent in the 6- and 12-month post-implementation interviews (p<.01). Conversely, approximately one-quarter of participants at both the 6- and 12-month post-implementation evaluation points reported that they were smoking crack more frequently since the availability of clean equipment--25 and 29 percent, respectively. In addition to a shift to a less harmful method of drug ingestion, HCV- and HIV-related risks associated with this method were reduced. Among crack-smoking IDUs sharing pipes, the proportion sharing "every time" declined from 37 percent in the 6-month pre-implementation stage, to 31 percent in the 1-month, 12 percent in the 6-month and 13 percent in the 12-month post-implementation stages (p<.01). Since distributing safer crack-smoking materials by a NEP contributes to transition to safer methods of drug ingestion and significantly reduces disease-related risk practices, other NEPs should adopt this practice.