Child-centred harm reduction.

Harm reduction has become increasingly influential in drug policy and practice, but has developed primarily around adult drug use. Theoretical, practical, ethical and legal issues pertaining to children and adolescents under the age of majority - both relating to their own use and the effects of drug use among parents or within the family - are less clear. This commentary proposes a sub-field of drug policy at the intersection of harm reduction and childhood which we refer to as 'child-centred harm reduction'. We provide a definition and conceptual model, as well as illustrative questions that emerge through a child-centred harm reduction lens. Many people in different countries are already working on these kinds of issues, whose work needs greater recognition, analysis and support. In beginning to name and define this sub-field we hope to improve this situation, and inspire further international debate, collaboration, and innovation.

Overdose among mothers: The association between child removal and unintentional drug overdose in a longitudinal cohort of marginalised women in Canada.

BACKGROUND: Accidental overdose is a major public health concern in North America with research primarily focused on cisgender men. Little is known about the burden of overdose among marginalised women, particularly in the context of child custody loss. This study aims to examine the prevalence of overdose and the association with child removal in a cohort of marginalised women. METHODS: This study draws on a merged dataset (2010-2018) of two community-based longitudinal cohorts of over 1000 marginalised women in Canada recruited using time-location sampling. After restricting to women who had ever had a live birth, bivariate and multivariable logistic regression using generalised estimating equations (GEE) were used to examine the association between child removal and overdose. Joint effects of child removal and Indigeneity were also investigated. RESULTS: Of the 696 women who reported ever having a live birth, 39.7% (n = 276) reported child removal at baseline. Unintended, non-fatal overdose rates were high, with 35.1% (n = 244) of women reporting ever having an overdose. Using bivariate GEE analyses, having a child apprehended and being Indigenous were positively correlated with overdose. Using multivariable GEE, child removal increased the odds of overdose by 55% (AOR: 1.55; 95% CI 1.01-2.39) after adjusting for education and Indigenous ancestry. Using multivariable joint-effects analysis, Indigenous women who had experienced child removal had over twice the odds of an unintended overdose than non-Indigenous women who had not lost custody after adjusting for education, food insecurity, and sex work (AOR: 2.09; 95% CI 1.15-3.79). CONCLUSION: This analysis suggests that, after controlling for known confounders, women who have a child removed experience higher odds of overdose, and these odds are highest among Indigenous women. The high prevalence of overdose in this cohort suggests the need for further strategies to prevent overdose among pregnant and parenting women.

Implementation of HIV treatment as prevention strategy in 17 Canadian sites: immediate and sustained outcomes from a 35-month Quality Improvement Collaborative.

BACKGROUND: Rapid scale-up of effective antiretroviral therapy (ART) is required to meet global targets to eliminate new HIV infections and AIDS-related deaths. Yet, gaps persist in all nations striving for these targets. In the intervention setting of British Columbia (BC), Canada, where ART is publicly funded, 73% of HIV-diagnosed were on ART in 2011, and only 49% were achieving viral suppression. METHODS: An observational case descriptive study of HIV care sites in BC recruited to participate in a 35-month Breakthrough Series Quality Improvement Collaborative and sustainability network. Sites collected four quality indicators, qualitative change descriptions and implemented the chronic care model (CCM) and HIV care and treatment guidelines. Two reviewers assigned monthly implementation scores to evaluate site progress (January 2011-2012). All quality indicators were pooled and analysed using probability-based run chart rules. RESULTS: Seventeen teams with a pooled median population of 2296 HIV patients joined the initiative. Comprehensive CCM implementation and evidence of improvement was achieved by 29% of sites (implementation score of 4.0 or higher on 5.0 scale). Evidence of sustained improvement was observed for patient engagement (88.8-90.4%), ART uptake among patients unequivocally in need (92.9-94.8%), and ART uptake (≥6 months) and achieving viral suppression (57.3-78.4%) (all p<0.05). CONCLUSIONS: This study shows evidence of sustained improvements in HIV care processes and treatment outcomes for an estimated population of 2296 HIV patients in 17 BC sites. Overall success points to opportunities for other high-income countries seeking to improve HIV health outcomes.

Relationship between disclosure of same-sex sexual activity to providers, HIV diagnosis and sexual health services for men who have sex with men in Vancouver, Canada.

OBJECTIVES: Men who have sex with men (MSM) report challenges to accessing appropriate health care. We sought to understand the relationship between disclosure of same-sex sexual activity to a health care practitioner (HCP), sexual behaviour and measures of sexual health care. METHODS: Participants recruited through community venues and events completed a questionnaire and provided a blood sample. This analysis includes only individuals with self-reported HIV negative or unknown serostatus. We compared participants who had disclosed having same-sex partners with those who had not using chi-square, Wilcoxon Rank Sum and Fisher's exact tests and used logistic regression to examine those variables associated with receiving an HIV test. RESULTS: Participants who had disclosed were more likely to have a higher level of education (p<0.001) and higher income (p<0.001), and to define themselves as "gay" or "queer" (p<0.001). Those who had not disclosed were less likely to report having risky sex (p=0.023) and to have been tested for HIV in the previous two years (adjusted odds ratio 0.23, 95% confidence interval: 0.16-0.34). There was no difference in undiagnosed HIV infection (3.9% versus 2.6%, p=0.34). Individuals who had disclosed were also more likely to have been tested for gonorrhea and syphilis, and more likely to have ever been vaccinated against hepatitis A and hepatitis B (p<0.001 for all). CONCLUSIONS: While generally reporting lower risk behaviour, MSM who did not disclose same-sex sexual activity to their HCP did have undiagnosed HIV infections and were less likely to have been tested or vaccinated. Strategies to improve access to appropriate sexual health care for MSM are needed.

Gaining insite: harm reduction in nursing practice.

Insite, a supervised injection facility in Vancouver, British Columbia, is an evidence-based response to the ongoing health and social crisis in the city's Downtown Eastside. It has been shown that Insite's services increase treatment referrals, mitigate the spread and impact of blood-borne diseases and prevent overdose deaths. One of the goals of this facility is to improve the health of those who use injection drugs. Nurses contribute to this goal by building trusting relationships with clients and delivering health services in a harm reduction setting. The authors describe nursing practice at Insite and its alignment with professional and ethical standards of registered nursing practice. Harm reduction is consistent with accepted standards for nursing practice as set out by the College of Registered Nurses of British Columbia and the Canadian Nurses Association and with World Health Organization guidelines.