Dispensation of antiretroviral therapy and methadone maintenance therapy at the same facility in a low-barrier setting linked to optimal adherence to HIV treatment.

OBJECTIVES: We sought to examine the association between dispensation of methadone maintenance therapy (MMT) and antiretroviral therapy (ART) at the same facility, across multiple low-barrier dispensing outlets, and achieving optimal adherence to ART among people who use illicit drugs (PWUD). METHODS: We used data from the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS) study, a long-running study of a community-recruited cohort of HIV-positive PWUD, linked to comprehensive HIV clinical records in Vancouver, Canada, a setting of no-cost, universal access to HIV care. The longitudinal relationship between MMT-ART dispensation at the same facility and the odds of ≥ 95% ART adherence was analysed using multivariable generalized linear mixed-effects modelling. We conducted a further analysis using a marginal structural mode with inverse probability of treatment weights as a sensitivity analysis. RESULTS: This study included data on 1690 interviews of 345 ART- and MMT-exposed participants carried out between June 2012 and December 2017. In the final multivariable model, MMT-ART dispensation, compared with nondispensation at the same facility, was associated with greater odds of achieving ≥ 95% adherence [adjusted odds ratio (AOR) 1.56; 95% confidence interval (CI) 1.26-1.96]. A marginal structural model estimated a 1.48 (95% CI 1.15-1.80) greater odds of ≥ 95% adherence among participants who reported MMT-ART dispensation at the same facility compared with those who did not. CONCLUSIONS: The odds of achieving optimal adherence to ART were 56% higher during periods in which MMT and ART medications were dispensed at the same facility, in a low-barrier setting. Our findings highlight the need to consider a simpler integrated approach with medication dispensation at the same facility in low-threshold settings.

Prevalence and Correlates of Reporting Difficulty Taking Antiretroviral Treatment Among HIV-Positive Illicit Drug Users in Vancouver, Canada: A Longitudinal Analysis.

People living with HIV who use illicit drugs continue to experience high rates of suboptimal treatment outcomes from antiretroviral therapy (ART). Although previous studies have identified important behavioural, social and structural barriers to ART adherence, the effects of patient-level factors have not been fully evaluated. Thus, we sought to investigate the prevalence and correlates of reporting ART was difficult to take among a cohort of illicit drug users in Vancouver, Canada. We accessed data from the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), an ongoing prospective cohort of HIV-positive illicit drug users linked to comprehensive HIV clinical monitoring records. We used generalized linear mixed-effects modeling to identify factors longitudinally associated with periods in which individuals reported they found ART difficult to take. Between December 2005 and May 2014, 746 ART-exposed illicit drug users were recruited and contributed at least one study interview. Finding ART hard to take was reported by 209 (28.0%) participants at baseline, and 460 (61.7%) participants throughout the study period. Patients ingesting a greater daily pill count (adjusted odds ratio [AOR] = 1.12 per pill, 95% confidence interval [CI] 1.08-1.17) and experiencing barriers to healthcare (AOR = 1.64, 95% CI 1.34-2.01) were more likely to report difficulty taking ART. Patients less likely to report satisfaction with their HIV physician (AOR = 0.76, 95% CI 0.58-1.00) and achieve a non-detectable HIV viral load (AOR = 0.62, 95% CI 0.51-0.74) were more likely to report finding ART hard to take. In this community-recruited cohort of ART-exposed illicit drug users, a substantial proportion reported they found HIV treatment hard to take, which was clearly linked to higher dissatisfaction with healthcare experiences and, most importantly, a lower likelihood of experiencing optimal virologic outcomes. Our findings reveal a number of opportunities to improve HIV treatment experiences and outcomes for people who use illicit drugs, including the use of treatment regimens with lower pill burdens, as well as reducing barriers to healthcare access.

Distance to HIV care and treatment adherence: Adjusting for socio-demographic and geographical heterogeneity.

Distance to health services plays an important role in determining access to care and an individual's health. This study aims to examine the relationship between distance to antiretroviral therapy (ART) prescribing physician and adherence to HIV treatment in British Columbia, Canada. Only participants who provided highly accurate locational data for both place of residence and their physician were used in the analysis. Using logistic regression, a multivariable confounder model was created to assess the association between distance and adherence. A geographically weighted logistic regression was also performed to adjust for spatial dependency. There were 1528 participants in the analysis, for a median distance of 17.85km. The final model showed further away from ART prescribing physician had a higher chance of incomplete adherence to ART (adjusted odds ratio 1.31; 95% Confidence Interval 1.04-1.65). Mobile services could potentially increase adherence rates for population residing further away from their ART prescribing physician.

Longitudinal trends of HIV drug resistance in a large Canadian cohort, 1996-2016.

OBJECTIVES: We aim to identify long-term trends in HIV drug resistance before and after combined antiretroviral therapy (cART) initiation. METHODS: IAS-USA (2015) mutations were identified in 23 271 HIV protease-reverse transcriptase sequences from 6543 treatment naïve adults in British Columbia. Participants who started cART between 1996 and 2014 were followed until April 2016. Equality of proportions test was used to compare the percentage of participants with acquired drug resistance (ADR) or transmitted drug resistance (TDR) in 1996, to those in 2014. Kaplan-Meier was used to estimate time to ADR in four drug resistance categories. Multivariable regression odds ratios (OR) of ADR for select clinical variables were determined by 5-year eras of cART initiation. RESULTS: The proportion of individuals with ADR declined from 39% (51/132) to 3% (8/322) in 1996-2014 (p <0.0001), while the proportion with TDR increased from 12% (16/132) to 18% (59/322) (p 0.14). The estimated proportions of individuals with ADR rose to 29% (NNRTI), 28% (3TC/FTC), 14% (other nRTI), and 7% (PI) after >16 years of therapy. After 5 years on therapy, participants initiating cART in 1996-2000 had 5.5-times more 3TC/FTC ADR, 5.3-times more other nRTI ADR, 4.7-times more NNRTI ADR, and 24-times more PI ADR than those starting in 2011-2014. The individuals with highest odds of developing ADR in 1996-2010 were adherent to regimens at levels between 60% and 80%, which shifted to <40% adherent in 2011-2014. CONCLUSIONS: HIV drug resistance transitioned from being primarily selected de-novo to being driven by TDR. Among those who started treatment in the past 5 years, ADR is rare and observed mostly in the lowest adherence strata.

High prevalence of willingness to use direct-acting antiviral-based regimens for hepatitis C virus (HCV) infection among HIV/HCV coinfected people who use drugs.

OBJECTIVES: Despite the high burden of hepatitis C virus (HCV)-related morbidity and mortality among HIV-positive people who use illicit drugs (PWUD), uptake of interferon-based treatments for HCV infection has been negligible among this group. Direct-acting antiviral (DAA) therapies offer an opportunity to expand treatment access among this population. The aim of this study was to explore willingness to use DAA-based regimens among HIV/HCV-coinfected PWUD in Vancouver, Canada. METHODS: Data were drawn from the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), a prospective cohort of HIV-positive PWUD. Using logistic regression analyses, we investigated factors associated with willingness to use DAA-based regimens among HIV/HCV-coinfected participants. RESULTS: Of 418 HIV/HCV-coinfected PWUD surveyed between June 2014 and May 2015, 295 (71%) were willing to use DAA-based regimens. In multivariable analysis, participants enrolled in methadone maintenance therapy [adjusted odds ratio (AOR) 1.61; 95% confidence interval (CI) 1.04-2.51], those with a recent assessment by an HCV specialist (AOR 2.02; 95% CI 1.28-3.19) and those who perceived that HCV infection was affecting their health (AOR 2.49; 95% CI 1.41-4.37) were more likely to be willing to use DAA-based regimens. CONCLUSIONS: Overall, this study found a high prevalence of willingness to use DAA-based regimens among HIV/HCV-coinfected PWUD in Vancouver. Importantly, enrolment in methadone maintenance therapy was positively associated with willingness, suggesting that integrated models of HIV, HCV and addiction care should be explored as a way to address HCV-related morbidity and mortality among HIV/HCV-coinfected PWUD.

Examining clinicians' experiences providing sexual health services for LGBTQ youth: considering social and structural determinants of health in clinical practice.

Although barriers related to lesbian, gay, bisexual, transgender and queer (LGBTQ) youth's experiences accessing sexual health services have been examined in detail, research into the experiences and perceptions of clinicians providing these services has been conspicuously absent. The aim of this article is to explore the perceptions and experiences of clinicians providing sexual health services for LGBTQ youth. Drawing on in-depth, semi-structured interviews, this study examines 24 clinicians' experiences providing sexual health services to LGBTQ youth in five communities in British Columbia, Canada. Our findings reveal how many clinicians provide services to LGBTQ youth with a lack of cultural competency-either implicitly (e.g., by describing heteronormative practices) or explicitly (e.g., by expressing frustration that they had not been sufficiently provided with appropriate training related to LGBTQ youth sexual health). Institutional norms and values were identified as the dominant barriers in the effective provision of LGBTQ-tailored services. Many clinicians find themselves unprepared to provide culturally competent sexual health services that have both the capacity to address individual-level issues (e.g. promoting condom use) while considering (and adapting services to) the broader socio-cultural and structural conditions that can render LGBTQ youth socially vulnerable.

Frequent methamphetamine injection predicts emergency department utilization among street-involved youth.

OBJECTIVES: Methamphetamine (MA) use has been associated with health problems that commonly present in the emergency department (ED). This study sought to determine whether frequent MA injection was a risk factor for ED utilization among street-involved youth. STUDY DESIGN: Prospective cohort study. METHODS: Data were derived from a street-involved youth cohort known as the 'At Risk Youth Study'. Behavioural data including MA use were linked to ED records at a major inner-city hospital. Kaplan-Meier and Cox proportional hazards methods were used to determine the risk factors for ED utilization. RESULTS: Between September 2005 and January 2007, 427 eligible participants were enrolled, among whom the median age was 21 (interquartile range 19-23) years and 154 (36.1%) were female. Within 1 year, 163 (38.2%) visited the ED, resulting in an incidence density of 53.7 per 100 person-years. ED utilization was significantly higher among frequent (i.e. ≥daily) MA injectors (log-rank P = 0.004). In multivariate analysis, frequent MA injection was associated with an increased hazard of ED utilization (adjusted hazard ratio = 1.84, 95% confidence interval 1.04-3.25; P = 0.036). CONCLUSIONS: Street-involved youth who frequently inject MA appear to be at increased risk of ED utilization. The integration of MA-specific addiction treatment services within emergency care settings for high-risk youth is recommended.

The street cost of drugs and drug use patterns: relationships with sex work income in an urban Canadian setting.

BACKGROUND: This study investigated the relationship between drug use and sex work patterns and sex work income earned among street-based female sex workers (FSWs) in Vancouver, Canada. METHODS: We used data from a sample of 129 FSWs who used drugs in a prospective cohort (2007-2008), for a total of 210 observations. Bivariate and multivariable linear regression using generalized estimating equations was used to model the relationship between explanatory factors and sex work income. Sex work income was log-transformed to account for skewed data. RESULTS: The median age of the sample at first visit was 37 years (interquartile range[IQR]: 30-43), with 46.5% identifying as Caucasian, 48.1% as Aboriginal and 5.4% as another visible minority. The median weekly sex work income and amount spent on drugs was $300 (IQR=$100-$560) and $400 (IQR=$150-$780), respectively. In multivariable analysis, for a 10% increase in money spent on drugs, sex work income increased by 1.9% (coeff: 0.20, 95% CIs: 0.04-0.36). FSWs who injected heroin, FSWs with higher numbers of clients and youth compared to older women (<25 versus 25+ years) also had significantly higher sex work income. CONCLUSIONS: This study highlights the important role that drug use plays in contributing to increased dependency on sex work for income among street-based FSWs in an urban Canadian setting, including a positive dose-response relationship between money spent on drugs and sex work income. These findings indicate a crucial need to scale up access and availability of evidence-based harm reduction and treatment approaches, including policy reforms, improved social support and economic choice for vulnerable women.

Prevalence and structural correlates of gender based violence among a prospective cohort of female sex workers.

OBJECTIVE: To examine the prevalence and structural correlates of gender based violence against female sex workers in an environment of criminalised prostitution. DESIGN: Prospective observational study. SETTING: Vancouver, Canada during 2006-8. PARTICIPANTS: Female sex workers 14 years of age or older (inclusive of transgender women) who used illicit drugs (excluding marijuana) and engaged in street level sex work. MAIN OUTCOME MEASURE: Self reported gender based violence. RESULTS: Of 267 female sex workers invited to participate, 251 women returned to the study office and consented to participate (response rate of 94%). Analyses were based on 237 female sex workers who completed a baseline visit and at least one follow-up visit. Of these 237 female sex workers, 57% experienced gender based violence over an 18 month follow-up period. In multivariate models adjusted for individual and interpersonal risk practices, the following structural factors were independently correlated with violence against female sex workers: homelessness (adjusted odds ratio for physical violence (aOR(physicalviolence)) 2.14, 95% confidence interval 1.34 to 3.43; adjusted odds ratio for rape (aOR(rape)) 1.73, 1.09 to 3.12); inability to access drug treatment (adjusted odds ratio for client violence (aOR(clientviolence)) 2.13, 1.26 to 3.62; aOR(physicalviolence) 1.96, 1.03 to 3.43); servicing clients in cars or public spaces (aOR(clientviolence) 1.50, 1.08 to 2.57); prior assault by police (aOR(clientviolence) 3.45, 1.98 to 6.02; aOR(rape) 2.61, 1.32 to 5.16); confiscation of drug use paraphernalia by police without arrest (aOR(physicalviolence) 1.50, 1.02 to 2.41); and moving working areas away from main streets owing to policing (aOR(clientviolence) 2.13, 1.26 to 3.62). CONCLUSIONS: Our results demonstrate an alarming prevalence of gender based violence against female sex workers. The structural factors of criminalisation, homelessness, and poor availability of drug treatment independently correlated with gender based violence against street based female sex workers. Socio-legal policy reforms, improved access to housing and drug treatment, and scale up of violence prevention efforts, including police-sex worker partnerships, will be crucial to stemming violence against female sex workers.

Youth's experiences with STI testing in four communities in British Columbia, Canada.

OBJECTIVES: To analyse the experiences of youths accessing sexually transmitted infection (STI) services and to examine the perspectives of service providers in four British Columbia communities. METHODS: In-depth qualitative interviews were completed with 70 young men and women (15-24 years). In total, 22 service providers (for example, clinicians, staff) were interviewed about their experiences providing STI testing services as well as the policies and practice guidelines that inform their work with youths. In addition, naturalistic observation was conducted at 11 clinic sites, including: youth clinics, doctors' offices, public health units and a large clinic specialising in STI testing. RESULTS: "Youth-friendly" STI testing services were rare despite being strongly desired by youth and service providers. Participants identified five barriers to accessing and/or providing youth-friendly STI testing: geography isolates many youths from testing service times or services, and presents privacy concerns, especially for rural youths. Clinic décor was perceived to be tailored for women and most service providers were female. Disclosing risky sexual behaviour to clinicians may be difficult for youths, especially for lesbian, gay, bisexual and transgender youths-particularly in contexts that are perceived to be homophobic. Many young women mistakenly believe that Pap smears include STI testing procedures, while many young men avoid testing because they fear the urethral swab and are unaware of alternative methods of specimen collection. CONCLUSION: This research reveals how structural and socio-cultural forces (for example, gender, place, physical space, culture) interact to shape the experiences of youths accessing STI testing services.

Mapping violence and policing as an environmental-structural barrier to health service and syringe availability among substance-using women in street-level sex work.

BACKGROUND: Within street-based sex work and substance-using populations, there is growing evidence to support the role of place, both physical setting and social meanings attached to place, in mediating the effectiveness and reach of health and harm reduction services. METHODS: Social mapping was used to explore how health service and syringe availability may be impacted at the geographic level by avoidance of physical settings due to violence and policing among women in street-level sex work. Through a community-based research partnership and extensive peer-led outreach over a 6-month period, women were invited to participate in interview-questionnaires and mapping of their community, working conditions, and access to resources. Results were compiled used ArcGIS software and GIS street maps. In secondary analysis, logistic regression was used to model the geographic association (using likelihood ratio and significance at p<0.05) and stratified models were run to assess differential patterns of avoidance based on age, ethnicity and drug use. RESULTS: The findings reveal a significant geographic relationship between a heavily concentrated core area of health and syringe availability and avoidance of physical settings due to violence and policing by 198 women in street-level sex work in Vancouver, Canada. Of particular concern, this correlation is significantly elevated among younger and Aboriginal women, active injection drug users, and daily crack cocaine smokers, suggesting significant environmental-structural barriers to interventions among these vulnerable populations. CONCLUSIONS: The resultant displacement of sex work to primarily industrial settings and side streets pushes women further from health and social supports and reduces access to safer injection and drug use paraphernalia. This study offers important evidence for environmental-structural level prevention and safer environment interventions, supported by legal reforms, that facilitate safer sex work environments, including spatial programming, peer-based prevention, outreach and mobile resources, and peer-supervised safer sex work settings.

Youth sexual behaviour in a boomtown: implications for the control of sexually transmitted infections.

BACKGROUND: Northeastern British Columbia, Canada, is undergoing rapid in-migration of young, primarily male, workers in response to the "boom" in the oil/gas industries. Chlamydia rates in the region exceed the provincial average by 32% (294.6 cases per 100 000 persons compared with 213.3). Evidence indicates that sociocultural and structural determinants of young people's sexual health are key to consider in the design of interventions. OBJECTIVES: To investigate how sociocultural and structural features related to the oil/gas boom are perceived to affect the sexual behaviour of youth in a Northeastern "boomtown". METHODS: The study included ethnographic fieldwork (8 weeks) and in-depth interviews with 25 youth (ages 15-25 years) and 14 health/social service providers. RESULTS: Participants identified four main ways in which the sociocultural and structural conditions created by the boom affect sexual behaviours, fuelling the spread of sexually transmitted infections (STIs): mobility of oil/gas workers; binge partying; high levels of disposable income and gendered power dynamics. CONCLUSIONS: The sociocultural and structural conditions that are fostered by a resource-extraction boom appear to exacerbate sexual health inequalities among youths who live and work in these rapidly urbanising, remote locales. To meet the needs of this population, we recommend STI prevention and testing service delivery models that incorporate STI testing outreach to oil/gas workers and condom distribution. Global, national and local STI control efforts should consider the realities and needs of similar subpopulations of young people.

Using structural equation modeling to examine factors that influence sunburn frequency and severity among adults living in Canada.

This study uses structural equation modeling to examine hypothesized relationships between sunburn and physical characteristics and potentially modifiable behavior. The analysis was based on self-reported data collected from a randomly selected national sample of Canadian adults. An initial model was tested with 50% of the cases (n = 1,408); the remaining cases (n = 1,298) were reserved for confirmatory testing. After the initial model failed, theoretically plausible effects were added incrementally to improve overall model fit. The initial model yielded: chi2(68 d.f.) = 3199.41 (P < .001) and the AGFI = .56. With 32 added effects, a fit model resulted in: chi2(36 d.f.) = 394.35 (P < .001), AGFI = 0.87, and IFI = 0.91 (the Critical-N was 210). Model fit was confirmed. Suntanning, failure to wear protective clothing, and sun exposure were associated with the frequency of severity-adjusted sunburns. Sunscreen use was not associated with sunburn frequency-severity.

Measuring self-reported sunburn: challenges and recommendations.

Sunburn is a major preventable risk associated with the development of malignant melanoma and basal cell carcinoma. Thus, it is considered a key epidemiological concept to assess in prevention research and a core component of routine behavioural surveillance and program evaluation efforts. This review examined 38 English- language survey instruments and research reports published between 1990 and 1999 that used self-report data or parent-proxy reports of sunburn outcome. A qualitative review of the instruments and reports identified several methodological issues: the conceptual and operation definitions of sunburn; the recall period, and the use of self-reports and parent-proxy reports. As there was little consistency in definitional issues or recall periods across the studies, it is difficult to meaningfully compare their findings. Key issues that program evaluators and researchers should consider in determining the strengths and limitations of various definitions, measures and approaches are examined. Recommendations for measurement of sunburn and for further research are included.

Canadian national workshop on measurement of sun-related behaviours [Workshop report].

The idea for the workshop described in this paper emerged from recommendations identified at the 1997 Workshop on Research, Policy and Program Planning on Sun Protective Behaviours. At the 1997 workshop, participants developed a set of recommendations for research initiatives related to sun protection efforts in Canada. One of the primary recommendations was to develop a standard set of definitions and core items to assess sun-related behaviours. In response, the authors of this paper agreed to co-chair the 1998 Canadian National Workshop on Measurement of Sun-Related Behaviours. The purpose of this workshop was to develop consensus on a standard set of measures for program evaluation and for monitoring of sun exposure and protective behaviours in Canada.

Canadian National Survey on Sun Exposure & Protective Behaviours: methods.

This article describes the methods used for the 1996 Canadian National Survey on Sun Exposure & Protective Behaviours. A 55-item random-digit-dialling telephone household survey of people 15 years of age or more was completed in 1996. Items assessed were daily sun exposure and protective behaviours, as well as other sun-related behaviours and attitudes. Data were collected regarding sun-related behaviours during leisure, work time and winter holidays, as well as for children 12 years of age or less (as reported by parents). To test for an effect on the survey response rate, a letter of introduction was sent to 40% of the households. The survey response rate was 69% (4023 successfully completed surveys out of 5847 households included in the sample). The response rate achieved in the subset that received the introductory letter was 75%. This survey is the first to establish national population estimates for sun exposure and protective behaviours in Canada.

Canadian National Survey on Sun Exposure & Protective Behaviours: adults at leisure.

OBJECTIVE: To describe the prevalence of sun exposure and protective behaviours during leisure time among Canadian adults 25 years of age or more. DESIGN: A random-digit-dialling telephone household survey of 4023 people 15 years of age or more was completed; 3449 adults 25 years of age or more responded to questions about sun exposure and protective behaviours from June to August 1996. RESULTS: Many of the adults (51%) reported getting 30 minutes to 2 hours of daily sun exposure, and 26% reported getting more than 2 hours. Half (50%) reported having one or more sunburns during the study period; 21% said they actively spent time suntanning. Less than half reported taking adequate protective actions. Women, light-complexioned and adults 65 years or more were more likely than men, medium- or dark-complexioned adults and adults in younger groups to protect themselves. Nearly two-thirds (63%) of the adults said they forgot to take protective actions, 47% felt it was inconvenient to do so, and 29% were not concerned about sun exposure. DISCUSSION: Canadian adults, especially younger men, are exposed to significant amounts of sun during summer leisure time, but they do not always protect themselves adequately. Interventions should emphasize and facilitate convenient, effective sun protection strategies.

Canadian National Survey on Sun Exposure & Protective Behaviours: youth at leisure.

OBJECTIVE: To describe the prevalence of sun exposure and protective behaviours during leisure time among Canadian youth 15 to 24 years of age. DESIGN: A random-digit-dialling telephone household survey of 4023 people 15 years of age or more was completed in 1996; 574 youth responded to questions about their sun exposure and protective behaviours from June to August 1996. RESULTS: Half of the youth (51%) reported 30 minutes to 2 hours of daily sun exposure, and 36% reported more than 2 hours. A large proportion (68%) reported sunburns. The prevalence of sun protective actions ranged from 38% for wearing a hat to 26% for both seeking shade and avoiding the sun between 11 am and 4 pm. There were sex differences in sun-related behaviours among youth. DISCUSSION: The large proportion of Canadian youth who reported sun exposure and the small proportion who reported taking protective actions suggest the need for primary prevention. Interventions should address sex differences and focus on multiple methods of protection.