The ethics of community-based research with people who use drugs: results of a scoping review.

BACKGROUND: Drug user networks and community-based organizations advocate for greater, meaningful involvement of people with lived experience of drug use in research, programs and services, and policy initiatives. Community-based approaches to research provide an opportunity to engage people who use drugs in all stages of the research process. Conducting community-based participatory research (CBPR) with people who use drugs has its own ethical challenges that are not necessarily acknowledged or supported by institutional ethics review boards. We conducted a scoping review to identify ethical issues in CBPR with people who use drugs that were documented in peer-reviewed and grey literature. METHODS: The search strategy focused on three areas; community-based research, ethical issues, and drug use. Searches of five academic databases were conducted in addition to a grey literature search, hand-searching, and consultation with organizational partners and key stakeholders. Peer reviewed literature and community reports published in English between 1985 and 2013 were included, with initial screening conducted by two reviewers. RESULTS: The search strategy produced a total of 874 references. Twenty-five references met the inclusion criteria and were included in our thematic analysis. Five areas were identified as important to the ethics of CBPR with people who use drugs: 1) participant compensation, 2) drug user perspectives on CBPR, 3) peer recruitment and representation in CBPR, 4) capacity building, and 5) participation and inclusion in CBPR. CONCLUSIONS: We critically discuss implications of the emerging research in this field and provide suggestions for future research and practice.

Modest rise in chlamydia and gonorrhoea testing did not increase case detection in a clinical HIV cohort in Ontario, Canada.

OBJECTIVES: We described patterns of testing for chlamydia and gonorrhoea infection among persons in specialty HIV care in Ontario, Canada, from 2008 to 2011. METHODS: We analysed data from 3165 participants in the OHTN Cohort Study attending one of seven specialty HIV care clinics. We obtained chlamydia and gonorrhoea test results via record linkage with the provincial public health laboratory. We estimated the proportion of participants who underwent testing annually, the positivity rate among those tested and the proportion diagnosed with chlamydia or gonorrhoea among all under observation. We explored risk factors for testing and diagnosis using multiple logistic regression analysis. RESULTS: The proportion tested annually rose from 15.2% (95% CI 13.6% to 16.7%) in 2008 to 27.0% (95% CI 25.3% to 28.6%) in 2011 (p<0.0001). Virtually all were urine-based nucleic acid amplification tests. Testing was more common among men who have sex with men (MSM), younger adults, Toronto residents, persons attending primary care clinics and persons who had tested in the previous year or who had more clinic visits in the current year. We observed a decrease in test positivity rates over time. However, the annual proportion diagnosed remained stable and in 2011 this was 0.97% (95% CI 0.61% to 1.3%) and 0.79% (95% CI 0.46% to 1.1%) for chlamydia and gonorrhoea, respectively. Virtually all cases were among MSM. CONCLUSIONS: Chlamydia and gonorrhoea testing increased over time while test positivity rates declined and the overall proportion diagnosed remained stable, suggesting that the modest increase in testing did not improve case detection.

What is low threshold methadone maintenance treatment?

BACKGROUND: Low threshold methadone maintenance (MMT) was developed for clients who do not have abstinence as a treatment goal. We explored how MMT programs in Canada defined low threshold and the challenges they faced. METHODS: Using semi-structured interviews, we collected data from clients (n=46), nurses/counsellors (n=15) and physicians (n=9) at three low threshold MMT programs. All participants were asked to define low threshold MMT and describe how it was implemented in practice. Interviews were taped, transcribed, verified and analysed using an iterative thematic coding technique. RESULTS: Low threshold MMT was defined by an explicit rejection of abstinence from opiates and other drugs as an over-arching treatment goal. In the absence of guidelines defining a set of practices as low threshold, programs implemented practices they believed would reduce barriers to admission and help retention. There was not always agreement between professional groups or across the programs regarding these practices. For physicians, there was a tension between accepting poly-drug use during treatment as a means to improve retention, with an obligation to do more good than harm for their patients. Missed prescribing appointments generated few to severe consequences and revealed differential focus on reducing barriers versus encouraging client 'ownership' of treatment. Differences of opinion regarding appropriate urine drug testing practices revealed power dynamics between medical and non-medical staff. CONCLUSION: Our findings show that there are potentially more ways to reduce barriers to MMT than those presented in the current literature. Our findings are important given the growing number of people with opiate dependence across the world and calls to increase access to MMT. To fully develop the low threshold model, it will be important to evaluate what policies and practices can achieve the goals of reducing barriers to admission and improving retention in treatment.

Acute and chronic respiratory symptoms among primary care patients who smoke crack cocaine.

Among inner-city populations in Canada, the use of crack cocaine by inhalation is prevalent. Crack smoking is associated with acute respiratory symptoms and complications, but less is known about chronic respiratory problems related to crack smoking. There is also a gap in the literature addressing the management of respiratory disease in primary health care among people who smoke crack. The purpose of our study was to assess the prevalence of acute and chronic respiratory symptoms among patients who smoke crack and access primary care. We conducted a pilot study among 20 patients who currently smoke crack (used within the past 30 days) and who access the "drop-in clinic" at an inner-city primary health care center. Participants completed a 20- to 30-min interviewer-administered survey and provided consent for a chart review. We collected information on respiratory-related symptoms, diagnoses, tests, medications, and specialist visits. Data were analyzed using frequency tabulations in SPSS (version 19.0). In the survey, 95 % (19/20) of the participants reported having at least one respiratory symptom in the past week. Thirteen (13/19, 68.4 %) reported these symptoms as bothersome. Chart review indicated that 12/20 (60 %) had a diagnosis of either asthma or chronic obstructive pulmonary disease (COPD), and four participants (4/20, 20 %) had a diagnosis of both asthma and COPD. Majority of the participants had been prescribed an inhaled medication (survey 16/20, 80 %; chart 12/20, 60 %). We found that 100 % (20/20) of the participants currently smoked tobacco, and 16/20 (80 %) had smoked both tobacco and marijuana prior to smoking crack. Our study suggests that respiratory symptoms and diagnoses of asthma and COPD are prevalent among a group of patients attending an inner-city clinic in Toronto and who also smoke crack. The high prevalence of smoking tobacco and marijuana among our participants is a major confounder for attributing respiratory symptoms to crack smoking alone. This novel pilot study can inform future research evaluating the primary health care management of respiratory disease among crack smokers, with the aim of improving health and health care delivery.

Frequent food insecurity among injection drug users: correlates and concerns.

BACKGROUND: Food insecurity and nutrition are two topics that are under-researched among injection drug users (IDUs). Our study examined the extent and correlates of food insecurity among a sample of IDUs and explored whether there is an association between food insecurity and injection-related HIV risk. METHODS: A cross-sectional survey was conducted using interviewer-administered questionnaires. Data were collected at a needle exchange program in London, Ontario, Canada between September 2006 and January 2007. Participants included 144 English-speaking IDUs who had injected drugs in the past 30 days. Participants were asked about their socio-demographic characteristics, HIV risk behaviours, food insecurity, and health/social service use. RESULTS: In the past 6 months, 54.5% of participants reported that on a daily/weekly basis they did not have enough to eat because of a lack of money, while 22.1% reported this type of food insecurity on a monthly basis. Moreover, 60.4% and 24.3% reported that they did not eat the quality or quantity of food they wanted on a daily/weekly or a monthly basis, respectively. Participants reported re-using someone else's injection equipment: 21% re-used a needle, 19% re-used water, and 37.3% re-used a cooker. The odds of sharing injection equipment were increased for food insecure individuals. CONCLUSIONS: Findings show that IDUs have frequent and variable experiences of food insecurity and these experiences are strongly correlated with sharing of injection-related equipment. Such behaviours may increase the likelihood of HIV and HCV transmission in this population. Addressing food-related needs among IDUs is urgently needed.

Prevalence and correlates of GB virus C infection in HIV-infected and HIV-uninfected pregnant women in Bangkok, Thailand.

GB virus C (GBV-C) is an apathogenic virus that has been shown to inhibit HIV replication. This study examined the prevalence and correlates of GBV-C infection and clearance in three cohorts of pregnant women in Thailand. The study population consisted of 1,719 (1,387 HIV-infected and 332 HIV-uninfected) women from three Bangkok perinatal HIV transmission studies. Stored blood was tested for GBV-C RNA, GBV-C antibody, and if RNA-positive, genotype. Risk factors associated with the prevalence of GBV-C infection (defined as presence of GBV-C RNA and/or antibody) and viral clearance (defined as presence of GBV-C antibody in the absence of RNA) among women with GBV-C infection were examined using multiple logistic regression. The prevalence of GBV-C infection was 33% among HIV-infected women and 15% among HIV-uninfected women. GBV-C infection was independently associated (AOR, 95% CI) with an increasing number of lifetime sexual partners (referent-1 partner, 2 partners [1.60, 1.22-2.08], 3-10 partners [1.92, 1.39-2.67], >10 partners [2.19, 1.33-3.62]); injection drug use (5.50, 2.12-14.2); and HIV infection (3.79, 2.58-5.59). Clearance of GBV-C RNA among women with evidence of GBV-C infection was independently associated with increasing age in years (referent <20, 20-29 [2.01, 1.06-3.79] and ≥30 [3.18, 1.53-6.60]), more than 10 lifetime sexual partners (3.05, 1.38-6.75), and HIV infection (0.29, 0.14-0.59). This study found that GBV-C infection is a common infection among Thai women and is associated with HIV infection and both sexual and parenteral risk behaviors.

Giving away used injection equipment: missed prevention message?

BACKGROUND: Our objective was to examine factors associated with distributive injection equipment sharing and how needle exchange programs (NEPs) can help reduce distributive sharing among injection drug users (IDUs). METHODS: 145 English speaking Canadian IDUs ages 16 years and over who had injected in the past 30 days were recruited for a cross-sectional survey. Participants were asked about their socio-demographic characteristics, HIV risk behaviours, social support, drug treatment readiness, program satisfaction, health and social service use and NEP drug use. Bivariate statistics and logistic regression were used to characterize the population and examine correlates of sharing behaviour. RESULTS: More IDUs reported distributive sharing of cookers (45%) than needles (36%) or other types of equipment (water 36%; filters 29%; swabs 8%). Regression analyses revealed the following factors associated with distributing used cookers: a history of cocaine/crack injection, an Addiction Severity Index (ASI) score indicative of a mental health problem, and older than 30 years of age. Factors associated with giving away used water included: male, injected methadone, injected other stimulants and moved 3+ times in the past 6 months. Factors associated with giving away used filters included: injected cocaine/crack or stayed overnight on the street or other public place. Factors associated with giving away swabs included: an ASI mental health score indicative of a mental health problem, and HCV negative status. CONCLUSIONS: Our findings show that more IDUs give away cookers than needles or other injection equipment. While the results showed that correlates of sharing differed by piece of equipment, each point to distributive sharing by the most marginalized IDUs. Targeting prevention efforts to reduce equipment sharing in general, and cookers in particular is warranted to reduce use of contaminated equipment and viral transmission.

Reduced mother-to-child transmission of HIV associated with infant but not maternal GB virus C infection.

BACKGROUND: Prolonged coinfection with GB virus C (GBV-C) has been associated with improved survival in human immunodeficiency virus (HIV)-infected adults. We investigated whether maternal or infant GBV-C infection was associated with mother-to-child transmission (MTCT) of HIV-1 infection. METHODS: The study population included 1364 HIV-infected pregnant women enrolled in 3 studies of MTCT of HIV in Bangkok, Thailand (the studies were conducted from 1992-1994, 1996-1997, and 1999-2004, respectively). We tested plasma collected from pregnant women at delivery for GBV-C RNA, GBV-C antibody, and GBV-C viral genotype. If GBV-C RNA was detected in the maternal samples, the 4- or 6-month infant sample was tested for GBV-C RNA. The rates of MTCT of HIV among GBV-C-infected women and infants were compared with the rates among women and infants without GBV-C infection. RESULTS: The prevalence of GBV-C RNA in maternal samples was 19%. Of 245 women who were GBV-C RNA positive, 101 (41%) transmitted GBV-C to their infants. Of 101 infants who were GBV-C RNA positive, 2 (2%) were infected with HIV, compared with 162 (13%) of 1232 infants who were GBV-C RNA negative (odds ratio [OR] adjusted for study, 0.13 [95% confidence interval {CI}, 0.03-0.54]). This association remained after adjustment for maternal HIV viral load, receipt of antiretroviral prophylaxis, CD4(+) count, and other covariates. MTCT of HIV was not associated with the presence of GBV-C RNA (adjusted OR [aOR], 0.94 [95% CI, 0.62-1.42]) or GBV-C antibody (aOR, 0.90 [95% CI, 0.54-1.50]) in maternal samples. CONCLUSIONS: Reduced MTCT of HIV was significantly associated with infant acquisition of GBV-C but not with maternal GBV-C infection. The mechanism for this association remains unknown.

Physician peer assessments for compliance with methadone maintenance treatment guidelines.

INTRODUCTION: Medical associations and licensing bodies face pressure to implement quality assurance programs, but evidence-based models are lacking. To improve the quality of methadone maintenance treatment (MMT), the College of Physicians and Surgeons of Ontario, Canada, conducts an innovative quality assurance program on the basis of peer assessments. Using data from this program, we assessed physician compliance with MMT guidelines and determined whether physician factors (e.g., training, years of practice), practice type, practice location, and/or caseload is associated with MMT guideline adherence. METHODS: Secondary analysis of methadone practice assessment data collected by the College of Physicians and Surgeons of Ontario, Canada. Assessment data from methadone prescribing physicians who completed their first year of methadone practice were analyzed. We calculated the mean percentage compliance per guideline per physician and global compliance across all guidelines per physician. Linear regression was used to assess factors associated with compliance. RESULTS: Data from 149 physician practices and 1,326 patient charts were analyzed. Compliance across all charts was greater than 90% for most areas of care. Compliance was less than 90% for take-home medication procedures; urine toxicology screening; screening for hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), tuberculosis, other sexually transmitted infections, and completion of a psychosocial assessment. Mean global compliance across all charts and guidelines per physician was 94.3% (standard deviation = 7.4%) with a range of 70% to 100%. Linear regression analysis revealed that only year of medical school graduation was a significant predictor of physician compliance. DISCUSSION: This is the first report of MMT peer assessments in Canada. Compliance is high. Few countries conduct similar assessment processes; none report physician-level results. We cannot quantify the contribution of peer assessment, training, or self-selection to the compliance rates, but compared to other areas of practice these rates suggest that peer assessment may exert a significant effect on compliance. A similar assessment process may in other areas of clinical practice improve physician compliance.

Longitudinal trends in antiretroviral use in a cohort of men and women in Ontario, Canada.

Initial studies have shown impaired access to antiretrovirals and slower adoption of new therapies by women. It is unclear if similar treatment delays still occur, especially in those with a publicly funded health care system in Ontario, Canada. The objectives of this study were (1) to evaluate longitudinal patterns of antiretroviral use in patients with HIV in Ontario and (2) to determine if gender differences exist in access to and uptake of antiretroviral drugs over time. A retrospective medical chart review was undertaken. One hundred four HIV-positive patients were recruited from nine hospital-based HIV outpatient clinics throughout Ontario. From time of study enrollment in 1999-2001 to the first clinic visit (8.1 +/- 3.2 years; range, 2.3-16.8 years), CD4+ T-cell counts, date of and agents used in initial antiretroviral regimen, and first HAART regimen were evaluated by gender. Kaplan-Meier plots were used to evaluate time to drug initiation from known HIV diagnosis. Serial cross sections of numbers and types of antiretroviral drugs prescribed in March, June, September, and December 1988 to 2001 were also compared as was number of regimens used. There were few differences between men and women in antiretroviral use; both initiated therapy within 2.2 +/- 2.3 years of HIV diagnosis at an average CD4 counts of 300.3 +/- 150.1 cells per microliter. Antiretroviral treatment regimens changed over time, with limited variation by gender. In the period immediately surrounding the first highly active antiretroviral therapy (HAART) recommendations by the U.S. Department of Health and Human Services in July 1997, significantly more antiretroviral drugs were prescribed for men than women. Antiretroviral prescribing in patients attending hospital- based HIV outpatient programs in Ontario is consistent with antiretroviral treatment guidelines over time, without substantial differences in antiretroviral access and use by gender.

Factors predicting 2-year retention in methadone maintenance treatment for opioid dependence.

Factors predicting 2-year retention in methadone maintenance and the impact of repeat treatment episodes on retention are examined. Data (n=9555 episodes) were drawn from a population-based treatment registry and analyses were performed using episode-weighted data. We estimated a binary logistic regression model with a duration of 730 days or greater as the dependent variable. The odds of remaining in treatment for 730 days or more increase with age and vary by region and provider type, but decrease with increasing number of treatment episodes. In comparison with other studies, these analyses show much higher rates of retention in methadone treatment but suggest that repeat episodes may not be as beneficial as existing research suggests.

Policy changes and the methadone maintenance treatment system for opioid dependence in Ontario, 1996 to 2001.

BACKGROUND: Until recently, the availability of methadone treatment in Ontario, Canada was limited. In 1996, policy changes were introduced to increase the availability of treatment. The 5-year impact of these policy changes is assessed. METHODS: For these census data, descriptive statistics were used to examine changes in the patient and provider populations over time using data from the College of Physicians and Surgeons of Ontario Methadone Maintenance Registry of Patients and the Registry of Methadone Prescribing Physicians. RESULTS: Between 1996 and 2001, the total number of clients in treatment increased substantially from: 1595 to 7787. Over this time period, the number of physicians prescribing methadone increased from 60 to 161. INTERPRETATION: Policy changes resulted in substantial increases in the patient and provider populations across Ontario. However, the estimated low proportion of opiate users in treatment indicates that more efforts are needed to address the potential demand for treatment.

Medicinal and recreational marijuana use by patients infected with HIV.

The goal of this study was to describe and compare the prevalence, predictors and patterns of marijuana use, specifically medicinal marijuana use among patients with HIV in Ontario, Canada. Any marijuana use in the year prior to interview and self-defined medicinal use were evaluated. A cross-sectional multicenter survey and retrospective chart review were conducted between 1999 and 2001 to evaluate overall drug utilization in HIV, including marijuana use. HIV-positive adults were identified through the HIV Ontario Observational Database (HOOD), 104 consenting patients were interviewed. Forty-three percent of patients reported any marijuana use, while 29% reported medicinal use. Reasons for use were similar by gender although a significantly higher number of women used marijuana for pain management. Overall, the most commonly reported reason for medicinal marijuana use was appetite stimulation/weight gain. Whereas male gender and history of intravenous drug use were predictive of any marijuana use, only household income less than $20,000 CDN was associated with medicinal marijuana use. Age, gender, HIV clinical status, antiretroviral use, and history of intravenous drug use were not significant predictors of medicinal marijuana use. Despite the frequency of medicinal use, minimal changes in the pattern of marijuana use upon HIV diagnosis were reported with 80% of current medicinal users also indicating recreational consumption. Although a large proportion of patients report medicinal marijuana use, overlap between medical and recreational consumption is substantial. The role of poverty in patient choice of medicinal marijuana despite access to care and the large proportion of women using marijuana for pain constitute areas for further study.

Pushing the boundaries of outreach work: the case of needle exchange outreach programs in Canada.

In this paper, we examine the challenges of defining the boundaries of outreach work using the example of needle exchange programs. In particular, we examine the multiple and inter-related factors that extend needle exchange outreach work beyond its official mandate. Using semi-structured interviews, 59 workers at 15 programs in Ontario, Canada were asked questions about operational policies and routines. An iterative and inductive analytic process was used. Over time, most outreach workers develop a well-defined sense of the activities they consider to be consistent with a harm reduction approach and the types of conduct that are considered to be acceptable and professional. Workers conceptualize their roles to encompass education and support but are reluctant to impose a rigid definition of their roles. A pragmatic and humble stance combined with strong beliefs in social justice encourages workers to find informal solutions to meet client needs that extend beyond the program mandate. As a result, doing 'extra' is the norm. These extra efforts are informal, but often regular, expansions of the service complement. Construction of flexible boundaries provides opportunities to meet many client needs and unexpected situations; however, going the extra-mile strains resources. A minority of workers blur the boundaries between private and professional lives. Further, a variety of personal, social and socio-political forces encourage outreach workers to continually redefine the boundaries of their roles and service complements.

Polypharmacy in HIV: impact of data source and gender on reported drug utilization.

Drug use in HIV is complex and may involve multiple therapeutic and nontherapeutic agents including prescription, over-the-counter, complementary and alternative medicine, and social/recreational drugs. This study was designed to assess the extent of such drug use in HIV-infected men and women. One hundred four adults were recruited through the HIV Ontario Observational Database from HIV outpatient clinics throughout Ontario, Canada. Patient demographics and data on drug use and physician awareness of drug use were collected through in-person interviews and medical chart review. All patient interviews and 96% of medical charts revealed the use of at least one drug. Eighty-five percent of patients reported use of antiretroviral medications; nearly 70% used highly active antiretroviral therapy. Patients used significantly more drugs by patient report (15.7 +/- 7.7) than by medical chart review (8.4 +/- 5.0) reporting up to 39 drugs per person. Pill burden was substantial, averaging 20.7 +/- 12.5 and ranged up to 69 "pills-per-day." Patient-reported physician awareness of drug use was highest for prescription drugs and lowest for social/recreational drugs; correspondingly agreement between medical chart and patient report ranged from 80% for antiretrovirals to 10% for non-prescribed drugs. The drug and pill burden faced by patients with HIV is considerable. Prevalence of use for specific drug classes varied with both data source and gender while number of drugs used differed only by data source. Our findings emphasize the complexity of pharmacotherapy in HIV and the need for comprehensive drug assessment, particularly because of the risks of drug-drug interactions and decreased adherence secondary to therapeutic complexity.

Prior opiate injection and incarceration history predict injection drug use among inmates.

AIMS: To describe injection drug use among inmates, and to identify correlates of drug injection while incarcerated. DESIGN: Cross-sectional survey. SETTING: Six provincial correctional centres in Ontario, Canada. PARTICIPANTS: Face-to-face interviews were conducted with a random sample of 439 adult males and 158 females. MEASUREMENTS: Inmates were asked about drug use in their lifetime, outside the year prior to their current incarceration, and while incarcerated in the past year. Among the 32% (189 / 597) with a prior history of drug injection, independent correlates of injection while incarcerated in the past year were identified using multiple logistic regression. FINDINGS: Among all inmates while incarcerated in the past year, 45% (269 /597) used drugs and 19% (113 / 596) used non-cannabis drugs. Among those with a prior history of injecting, 11% (20 / 189) injected while incarcerated in the past year. Rates of injection with used needles were the same pre-incarceration as they were while incarcerated (32%). Independent correlates of drug injection while incarcerated were injection of heroin (OR = 6.4) or other opiates (OR = 7.9) and not injected with used needles (OR = 0.20) outside in the year prior to incarceration, and ever being incarcerated in a federal prison (OR = 5.3). CONCLUSIONS: The possibility of transmission of human immunodeficiency virus (HIV), hepatitis C (HCV) or other blood-borne diseases exists in Ontario correctional centres. In this setting, drug injection while incarcerated is primarily related to opiate use prior to incarceration. The correlation between injecting and extensive incarceration history suggests missed opportunities to improve inmates' health.

Use of complementary and alternative medicine by HIV-infected outpatients in Ontario, Canada.

Little is known about complementary and alternative medicine (CAM) use in Canadian patients with HIV. We sought to determine the prevalence of CAM use by patients attending HIV outpatient clinics in Ontario, Canada, and to compare the characteristics of users and nonusers. Impact of CAM definition on reported utilization rates was also assessed, specifically in relation to the inclusion and exclusion of vitamins, minerals, and multivitamins in CAM definition. In-person interviews were conducted between 1999 and 2001 with 104 HIV-positive outpatients enrolled in the HIV Ontario Observational Database project (HOOD) and attending HIV outpatient clinics in Ontario. Self-reported CAM utilization and demographic data were collected. Clinical data were obtained from medical chart review. Seventy-seven percent of participants reported current CAM use. Inclusion of vitamins and minerals (CAMVIT) increased this estimate to 89%. Nearly all patients used CAM in conjunction with antiretroviral medications. Out of pocket costs ranged from CAD$0 to more than CAD$250 per month. Most patients reported CAM use was beneficial and had improved their overall health. Female gender, HIV risk group, number of prescriptions, and overall number of drugs used were associated with CAM use. CAM use in Canadian patients with HIV is extremely common, with higher use among women. The definition of CAM has a substantial impact both on reported prevalence rates and on predictors of CAM use.

Voluntary HIV testing among inmates: sociodemographic, behavioral risk, and attitudinal correlates.

We sought to determine the prevalence and correlates of self-reported HIV testing among inmates in correctional centers in Ontario, Canada. A cross-sectional survey was conducted with a stratified random sample of 597 male and female adult inmates. The participation rate was 89%. Descriptive statistics and multiple logistic regression were used to analyze HIV testing. Fifty-eight percent had ever been tested, and 21% had voluntarily tested while incarcerated in the past year. Having ever been tested was more common among those at risk for HIV through injection drug use (IDU) or sexual behavior. Testing while incarcerated in the past year was independently associated with being single (OR = 2.6), frequent IDU (OR = 4.0), not having casual sex partners prior to incarceration (OR = 0.53), a history of hepatitis (OR = 2.4), previous HIV testing (OR = 3.7), a close relationship with an HIV-positive person in the outside community (OR = 1.7), knowing an HIV-positive person inside (OR = 2.7), a perceived chance of being infected during incarceration (OR = 2.2), and support of mandatory testing (OR = 2.0). The predominant motivations for testing while incarcerated were IDU or fears of infection inside, possibly through contact with blood, during fights, or even by casual contact. Voluntary HIV testing in prison should be encouraged, and inmates should receive appropriate counseling and information to allow realistic assessment of risk.

Delayed application of condoms is a risk factor for human immunodeficiency virus infection among homosexual and bisexual men.

The objective of this analysis was to identify risk factors for recent human immunodeficiency virus (HIV) infection among homosexual and bisexual men in Ontario, Canada, during 1998-2001. Participants were recruited through the provincial HIV diagnostic laboratory and through physicians and community organizations. HIV test results were used to identify recent seroconverters (cases). A subsample of 183 men (62 cases and 121 controls) enrolled in the Polaris HIV Seroconversion Study as of June 2001 was analyzed. This analysis focused on sexual behaviors with partners who were HIV-positive or whose HIV status was unknown. In multiple logistic regression, independent risk factors were identified. Rates of unprotected receptive oral, insertive anal, and receptive anal sex and delayed application of condoms during receptive anal sex (RAS) were significantly higher among cases (97%, 41%, 53%, and 32%, respectively) than among controls (73%, 19%, 14%, and 2%). Independent risk factors for HIV infection were RAS without condoms (odds ratio = 4.4, p = 0.0004) and delayed application of condoms during RAS (odds ratio = 5.8, p = 0.01). There was an association with condom failure (breakage or slippage) during RAS that approached significance (odds ratio = 2.9, p = 0.09). Delayed application of condoms for RAS may result in contact with preejaculatory fluid. This behavior, which to date has received little attention, may pose as much risk for HIV infection as fully unprotected RAS.

Needle exchange programs. Delivery and access issues.

OBJECTIVE: Examine the challenges of four service delivery models (i.e., fixed, mobile, satellite and home visits) and how service delivery may impact on NEP HIV prevention efforts. METHODS: Using a modified ethnographic approach, semi-structured interviews concerning policies and procedures were conducted with staff (n = 59) of NEPs (n = 15) in Ontario. An iterative, inductive analytic process was used. RESULTS: According to workers and managers, effectiveness of NEP prevention efforts depend on client development and retention and service design. Fixed and satellite sites, home visits and mobile services provide varied levels of temporal and spatial accessibility. Combining modes of delivery can offset the disadvantages of individual modes. DISCUSSION: NEP evaluations that do not consider service and resource factors run the risk of concluding that NEPs are ineffective when it may be that the program works for a small proportion of IDUs whom the NEP has the resources to serve.