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Fursman H, Finch E, Xiao L, Lefrançois E, Gupta A, Bartlett M, Latimer J, Chadwick S, Roux C, Morelato M. A snapshot of injecting drug consumption from the analysis of used syringes within the Medically Supervised Injecting Centre in Sydney, Australia. Drug Alcohol Rev 2024; 43:787-798. [PMID: 38145366 DOI: 10.1111/dar.13803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION The administration of illicit drugs by injection is associated with considerable harm, including an increased risk of overdose. The chemical analysis of used syringes can enhance knowledge on injecting drug consumption beyond traditional data sources (self-report surveys). This additional information may be useful during significant global events like the COVID-19 pandemic. This study aimed to examine a snapshot of the drugs injected at the Medically Supervised Injecting Centre (MSIC) in Sydney, Australia, in 2019-2020. METHODS Used syringes were collected from MSIC across three periods throughout 2019 and 2020 (February 2019, March-April 2020 and June-September 2020). Drug residues were extracted from used syringes using methanol before detection by gas chromatography-mass spectrometry and ultra-performance liquid chromatography-tandem mass spectrometry. The chemical analysis results were compared to self-report data obtained from MSIC clients. RESULTS Heroin (46-53%), methamphetamine (24-34%) and pharmaceutical opioids (15-27%) were the most common drug residues detected. The chemically detected drugs had declining coherence with the drugs self-reported by MSIC clients across the time periods examined. DISCUSSION AND CONCLUSIONS There was no significant change in the drugs injected (heroin, methamphetamine and pharmaceutical opioids) across the three periods collected throughout varying COVID-19 lockdown restrictions. Changes in the frequency of other drugs injected and discrepancies between chemical analysis and self-report were potentially related to regulatory changes, degradation or misinformed sales. Routine chemical analysis of used syringes has provided an alternative information source to promote awareness of current drug trends and aid harm reduction.
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Affiliation(s)
- Harrison Fursman
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
| | - Eleanor Finch
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
| | - Linda Xiao
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
| | - Elodie Lefrançois
- School of Criminal Justice, Faculty of Law, Criminal Justice and Public Administration, University of Lausanne, Lausanne, Switzerland
| | - Anjali Gupta
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
| | - Mark Bartlett
- Uniting Medically Supervised Injecting Centre, Sydney, Australia
| | - Julie Latimer
- Uniting Medically Supervised Injecting Centre, Sydney, Australia
| | - Scott Chadwick
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
| | - Claude Roux
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
| | - Marie Morelato
- Centre for Forensic Science, University of Technology Sydney, Sydney, Australia
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Gjerde H, Bretteville-Jensen AL, Bache-Andreassen L, Hanoa K, Furuhaugen H, Brochmann GW, Vindenes V. Which illicit drugs are injected in Oslo? A study based on analysis of drug residues in used injection equipment and self-reported information. Scand J Public Health 2023; 51:21-27. [PMID: 34538164 PMCID: PMC9900188 DOI: 10.1177/14034948211043984] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND People who inject drugs (PWID) have a high risk of premature death due to fatal overdoses. Newly emerged fentanyls, much more potent than heroin and other opioids, may increase this risk further. Therefore, precise information on injected drugs is critical to improving prevention strategies. AIMS This study aimed to analyse drug residues in used injection equipment in order to determine drug and drug combinations and compare and complement findings with self-reported information. METHODS Used syringes and needles (n=766) were collected at the supervised drug consumption facilities, the needle exchange service and two low-threshold health services for problem drug users in Oslo, Norway. The material was collected every third month from June 2019 to June 2020 and analysed for 64 substances using highly specific analytical methods (ultra-high performance liquid chromatography tandem mass spectrometry). Additionally, a street-recruited sample of PWID was interviewed from 2017 to 2019 regarding their drug injection habits (n=572). RESULTS Heroin (65.5%) or amphetamines (59.8%), often in combination (30.5%), were commonly detected in drug residues. Other opioids, stimulants or benzodiazepines were rarely detected (6.1%). Fentanyl was detected in only one syringe. Heroin was the most reported drug (77.6% during the past four weeks, 48.3% daily/almost daily), followed by amphetamines (57.5% during the past four weeks, 23.1% daily or almost daily). Injection of methadone, buprenorphine and dissolved tablets was self-reported more frequently than determined in drug residue findings. CONCLUSIONS
Analysis of the injection equipment proved useful as a non-invasive, rapid and accurate means to obtain detailed information on injected drugs in Oslo and supplement traditional PWID survey information.
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Affiliation(s)
- Hallvard Gjerde
- Section of Drug Abuse Research,
Department of Forensic Sciences, Oslo University Hospital, Norway,Hallvard Gjerde, Oslo University Hospital,
Department of Forensic Sciences, Section for Drug Abuse Research, P.O. Box 4950
Nydalen, NO-0424 Oslo, Norway. E-mail:
| | | | - Lihn Bache-Andreassen
- Section of Drug Abuse Research,
Department of Forensic Sciences, Oslo University Hospital, Norway
| | - Kristin Hanoa
- Department of Alcohol, Tobacco and
Drugs, Norwegian Institute of Public Health, Norway
| | - Håvard Furuhaugen
- Section of Drug Abuse Research,
Department of Forensic Sciences, Oslo University Hospital, Norway
| | - Gerd-Wenche Brochmann
- Section of Drug Abuse Research,
Department of Forensic Sciences, Oslo University Hospital, Norway
| | - Vigdis Vindenes
- Section of Drug Abuse Research,
Department of Forensic Sciences, Oslo University Hospital, Norway,Institute of Clinical Medicine, Faculty
of Medicine, University of Oslo, Norway
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West H, Fitzgerald JL, Hopkins KL, Leeming MG, DiRago M, Gerostamoulos D, Clark N, Dietze P, White JM, Ziogas J, Reid GE. Trace residue identification, characterization, and longitudinal monitoring of the novel synthetic opioid β-U10, from discarded drug paraphernalia. Drug Test Anal 2022; 14:1576-1586. [PMID: 35562123 PMCID: PMC9542064 DOI: 10.1002/dta.3284] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/01/2022] [Accepted: 05/10/2022] [Indexed: 11/08/2022]
Abstract
Empirical data regarding dynamic alterations in illicit drug supply markets in response to the COVID-19 pandemic, including the potential for introduction of novel drug substances and/or increased poly-drug combination use at the "street" level, that is, directly proximal to the point of consumption, are currently lacking. Here, a high-throughput strategy employing ambient ionization-mass spectrometry is described for the trace residue identification, characterization, and longitudinal monitoring of illicit drug substances found within >6,600 discarded drug paraphernalia (DDP) samples collected during a pilot study of an early warning system for illicit drug use in Melbourne, Australia from August 2020 to February 2021, while significant COVID-19 lockdown conditions were imposed. The utility of this approach is demonstrated for the de novo identification and structural characterization of β-U10, a previously unreported naphthamide analog within the "U-series" of synthetic opioid drugs, including differentiation from its α-U10 isomer without need for sample preparation or chromatographic separation prior to analysis. Notably, β-U10 was observed with 23 other drug substances, most commonly in temporally distinct clusters with heroin, etizolam, and diphenhydramine, and in a total of 182 different poly-drug combinations. Longitudinal monitoring of the number and weekly "average signal intensity" (ASI) values of identified substances, developed here as a semi-quantitative proxy indicator of changes in availability, relative purity and compositions of street level drug samples, revealed that increases in the number of identifications and ASI for β-U10 and etizolam coincided with a 50% decrease in the number of positive detections and an order of magnitude decrease in the ASI for heroin.
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Affiliation(s)
- Henry West
- School of ChemistryThe University of MelbourneParkvilleVictoriaAustralia
| | - John L. Fitzgerald
- School of Social and Political ScienceThe University of MelbourneParkvilleVictoriaAustralia
| | - Katherine L. Hopkins
- School of ChemistryThe University of MelbourneParkvilleVictoriaAustralia
- School of Social and Political ScienceThe University of MelbourneParkvilleVictoriaAustralia
| | - Michael G. Leeming
- Melbourne Mass Spectrometry and Proteomics Facility, Bio21 Molecular Science and Biotechnology InstituteThe University of MelbourneParkvilleVictoriaAustralia
| | - Matthew DiRago
- Victorian Institute of Forensic MedicineSouthbankVictoriaAustralia
- Department of Forensic MedicineMonash UniversityClaytonVictoriaAustralia
| | - Dimitri Gerostamoulos
- Victorian Institute of Forensic MedicineSouthbankVictoriaAustralia
- Department of Forensic MedicineMonash UniversityClaytonVictoriaAustralia
| | - Nicolas Clark
- North Richmond Community HealthRichmondVictoriaAustralia
- Addiction Medicine ServiceRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Paul Dietze
- National Drug Research Institute and enAble InstituteCurtin UniversityMelbourneVictoriaAustralia
- Disease Elimination ProgramBurnet InstituteMelbourneVictoriaAustralia
| | - Jonathan M. White
- School of ChemistryThe University of MelbourneParkvilleVictoriaAustralia
| | - James Ziogas
- Department of Biochemistry and PharmacologyThe University of MelbourneParkvilleVictoriaAustralia
| | - Gavin E. Reid
- School of ChemistryThe University of MelbourneParkvilleVictoriaAustralia
- Department of Biochemistry and PharmacologyThe University of MelbourneParkvilleVictoriaAustralia
- Bio21 Molecular Science and Biotechnology InstituteThe University of MelbourneParkvilleVictoriaAustralia
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Substances detected in used syringes of injecting drug users across 7 cities in Europe in 2017 and 2018: The European Syringe Collection and Analysis Project Enterprise (ESCAPE). THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 95:103130. [PMID: 33487529 DOI: 10.1016/j.drugpo.2021.103130] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/31/2020] [Accepted: 01/06/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND AIMS Injecting drug use is a matter of public health concern, associated with risks of overdoses, addiction and increased risk of bloodborne viral transmissions. Self-reported data on substances injected can be inaccurate or subject to bias or drug users might be oblivious to their injected substances or adulterations. Gathering of robust analytical information on the actual composition of substances injected might provide better information about the drugs that are being used. Therefore, this study aimed to analyse the residual content of discarded syringes collected across 7 European cities, collectively called the European Syringe Collection and Analysis Project Enterprise (ESCAPE). METHODS Used syringes were collected at street automatic injection kit dispensers or at harm-reduction services in Amsterdam, Budapest, Cologne, Glasgow, Helsinki, Lausanne and Paris. Two sampling periods were executed thus far, in 2017 and 2018. Qualitative chemical analysis of the content of used syringes was performed combining gas chromatographic (GC) and ultra(high)performance liquid chromatographic ((U)HPLC) analytical techniques with detection by mass spectrometry (MS). RESULTS Substances detected most frequently across both campaigns were cocaine, heroin, buprenorphine, amphetamines and synthetic cathinones. In Amsterdam, Cologne, Lausanne and Glasgow heroin and cocaine were the psychoactive substances most often detected, often in conjunction with each other. Helsinki showed a high presence of buprenorphine and amphetamines. In Budapest and Paris, synthetic cathinones were frequently detected. Less synthetic cathinones and cocaine was detected in 2018, whereas buprenorphine was detected almost twice as much. Inner-city variations were found, probably reflecting the types of people who inject drugs (PWID) in different areas of the city. CONCLUSION Overall, laboratory-confirmed local data on injected substances showed resemblance to national surveys done among PWID. However, the ESCAPE data also showed some interesting differences, showing it can be used for local interventions and complementing existing monitoring data.
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Jones NS, Comparin JH. Interpol review of controlled substances 2016-2019. Forensic Sci Int Synerg 2020; 2:608-669. [PMID: 33385148 PMCID: PMC7770462 DOI: 10.1016/j.fsisyn.2020.01.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/23/2020] [Indexed: 12/14/2022]
Abstract
This review paper covers the forensic-relevant literature in controlled substances from 2016 to 2019 as a part of the 19th Interpol International Forensic Science Managers Symposium. The review papers are also available at the Interpol website at: https://www.interpol.int/content/download/14458/file/Interpol%20Review%20Papers%202019.pdf.
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Affiliation(s)
- Nicole S. Jones
- RTI International, Applied Justice Research Division, Center for Forensic Sciences, 3040 E. Cornwallis Road, Research Triangle Park, NC, 22709-2194, USA
| | - Jeffrey H. Comparin
- United States Drug Enforcement Administration, Special Testing and Research Laboratory, USA
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Analytical findings in used syringes from a syringe exchange program. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 81:102770. [PMID: 32442881 DOI: 10.1016/j.drugpo.2020.102770] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/19/2020] [Accepted: 04/22/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Since it's first implementatation in 1984, Syringe Exchange Programs (SEP) are a critical component of harm reduction interventions among people who inject drugs.. The aim of this work was to use a scientific analytical approach to obtain drug use information through the analysis of the content of used syringes. METHODS 357 syringes were collected in New York City and submitted to qualitative analysis. Screening analysis was performed by gas chromatography mass spectrometry (GC-MS) and confirmatory analysis by liquid chromatography quadrupole time of flight mass spectrometry (LC-QTOF). RESULTS Of the 357 syringes analyzed, 275 (77.0%) were positive for one or more substances. The most common drug of abuse identified was heroin/related substances (72.0%), followed by cocaine/related substance (34.9%), fentanyl/related substance (13.5%), methamphetamine/related substance (7.6%) and furanylfentanyl (3.6%). Quinine/quinidine (18.5%) was the most common cutting agent detected, followed by levamisole (12.0%), caffeine (11.6%), lidocaine (11.6%), and phenacetin (6.9%). CONCLUSION Analysis of samples collected from a drug street scenario allows the identification of new substances being injected and provides information to harm reduction programs to identify strategies to reduce drug abuse.
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Gjerde H, Bretteville-Jensen AL, Furuhaugen H, Bache-Andreassen L, Bergh MSS, Vindenes V. Determination of drug residues in used syringe needles. Drug Test Anal 2020; 12:410-416. [PMID: 31899604 DOI: 10.1002/dta.2759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/02/2019] [Accepted: 12/28/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Hallvard Gjerde
- Section of Drug Abuse Research, Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
| | | | - Håvard Furuhaugen
- Section of Drug Abuse Research, Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
| | - Lihn Bache-Andreassen
- Section of Drug Abuse Research, Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
| | - Marianne Skov-Skov Bergh
- Section of Drug Abuse Research, Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
| | - Vigdis Vindenes
- Section of Drug Abuse Research, Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway.,University of Oslo, Faculty of Medicine, Institute of Clinical Medicine, Oslo, Norway
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Class-specific determination of fluoroquinolones based on a novel chemiluminescence system with molecularly imprinted polymers. Food Chem 2019; 298:125066. [DOI: 10.1016/j.foodchem.2019.125066] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/10/2019] [Accepted: 06/23/2019] [Indexed: 01/12/2023]
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Øvrehus A, Nielsen S, Hansen JF, Holm DK, Christensen P. Test uptake and hepatitis C prevalence in 5483 Danish people in drug use treatment from 1996 to 2015: a registry-based cohort study. Addiction 2019; 114:494-503. [PMID: 30347471 DOI: 10.1111/add.14479] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/02/2018] [Accepted: 10/17/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The aims of this study were, in people in treatment for drug use in Funen, Denmark, to: (1) assess prevalence of hepatitis C virus (HCV) test uptake and prevalence of HCV; (2) identify predictors of test update and HCV infection; and (3) characterize changes between 1996 and 2015 in test uptake, HCV prevalence and drug use. DESIGN Cohort study linking the Danish National Registry on Drug Users in Treatment to the regional hepatitis test registry and the Danish Death Certificate Registry, thus combining longitudinal data on drug use with data on HCV testing and results. SETTING AND PARTICIPANTS People recorded as having received treatment for drug use between 1996 and 2015 (n = 5483) in Funen, Denmark. In the cohort, 24.8% were female, median age 23 years [interquartile range (IQR) = 20-32] at entry and 50% had self-reported injecting or had received opiate substitution therapy (OST). MEASUREMENTS The main outcomes were the test for HCV ever and latest HCV-RNA being positive. The main predictors were for test and infection investigated; ever receiving OST, self-reported injecting, age at entry and connection to treatment centre offering outreach hepatitis care. FINDINGS HCV test uptake was 52% and prevalence of current HCV-RNA+ was 21% in people alive at the end of follow-up. Positive predictors of having undergone HCV testing were: receiving OST [odds ratio (OR) = 3.7; 95% confidence interval (CI) = 3.2-4.5], self-reported injecting (OR = 2.3; 95% CI = 2.0-2.7), female gender (OR = 1.7; 95% CI = 1.4-1.9) and having been connected to centres with outreach hepatitis care (OR = 1.4; 95% CI = 1.2-1.7). In people alive, HCV-RNA+ prevalence was 31% if ever on OST or self-reported injecting. Among HCV-infected people, 69% were in drug use treatment at end of follow-up. For participants entering the cohort after 2010, only 5% reported opiates as main drug of use and 17% had experience of injecting. CONCLUSION Among Danish people in treatment for drug use from 1996 to 2015, receiving opiate substitution therapy had the largest associating to being tested for hepatitis C virus. As opiate use is declining, adapting test strategies will be necessary.
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Affiliation(s)
- Anne Øvrehus
- Department of Infectious Diseases, Odense University Hospital, Odense C, Denmark
| | - Stine Nielsen
- Department of Infectious Diseases, Odense University Hospital, Odense C, Denmark
| | | | - Dorte Kinggaard Holm
- Department of Clinical Immunology, Odense University Hospital, Odense C, Denmark
| | - Peer Christensen
- Department of Infectious Diseases, Odense University Hospital, Odense C, Denmark
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Karamouzian M, Dohoo C, Forsting S, McNeil R, Kerr T, Lysyshyn M. Evaluation of a fentanyl drug checking service for clients of a supervised injection facility, Vancouver, Canada. Harm Reduct J 2018; 15:46. [PMID: 30200991 PMCID: PMC6131768 DOI: 10.1186/s12954-018-0252-8] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/27/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND British Columbia, Canada, is experiencing a public health emergency related to opioid overdoses driven by consumption of street drugs contaminated with illicitly manufactured fentanyl. This cross-sectional study evaluates a drug checking intervention for the clients of a supervised injection facility (SIF) in Vancouver. METHODS Insite is a facility offering supervised injection services in Vancouver's Downtown East Side, a community with high levels of injection drug use and associated harms, including overdose deaths. During July 7, 2016, to June 21, 2017, Insite clients were offered an opportunity to check their drugs for fentanyl using a test strip designed to test urine for fentanyl. Results of the drug check were recorded along with information including the substance checked, whether the client intended to dispose of the drug or reduce the dose and whether they experienced an overdose. Logistic regression models were constructed to assess the associations between drug checking results and dose reduction or drug disposal. Crude odds ratios (OR) and 95% confidence intervals (CI) were reported. RESULTS About 1% of the visits to Insite during the study resulted in a drug check. Out of 1411 drug checks conducted by clients, 1121 (79.8%) were positive for fentanyl. Although most tests were conducted post-consumption, following a positive pre-consumption drug check, 36.3% (n = 142) of participants reported planning to reduce their drug dose while only 11.4% (n = 50) planned to dispose of their drug. While the odds of intended dose reduction among those with a positive drug check was significantly higher than those with a negative result (OR = 9.36; 95% CI 4.25-20.65), no association was observed between drug check results and intended drug disposal (OR = 1.60; 95% CI 0.79-3.26). Among all participants, intended dose reduction was associated with significantly lower odds of overdose (OR = 0.41; 95% CI 0.18-0.89). CONCLUSIONS Although only a small proportion of visits resulted in a drug check, a high proportion (~ 80%) of the drugs checked were contaminated with fentanyl. Drug checking at harm reduction facilities such as SIFs might be a feasible intervention that could contribute to preventing overdoses in the context of the current overdose emergency.
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Affiliation(s)
- Mohammad Karamouzian
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
- School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC V6T 1Z3 Canada
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, 7616913555 Iran
| | - Carolyn Dohoo
- Public Health Agency of Canada, Ottawa, ON K1A 0K9 Canada
| | - Sara Forsting
- Vancouver Coastal Health Authority, Vancouver, BC V5Z 4C2 Canada
| | - Ryan McNeil
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Mark Lysyshyn
- School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC V6T 1Z3 Canada
- Vancouver Coastal Health Authority, Vancouver, BC V5Z 4C2 Canada
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