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Abramovich A, Gould WA, Pang N, de Oliveira C, Iwajomo T, Vigny-Pau M, MacKinnon K, Lam JSH, Kurdyak P. Exploring Mediators of Mental Health Service Use Among Transgender Individuals in Ontario, Canada. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2023; 68:933-948. [PMID: 37165522 PMCID: PMC10657585 DOI: 10.1177/07067437231171541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To determine if and to what degree neighbourhood-level marginalization mediates mental health service use among transgender individuals. METHODS This retrospective cohort study identified 2,085 transgender individuals through data obtained from 4 outpatient community and hospital clinics in 3 large cities in Ontario, which were linked with administrative health data between January 2015 and December 2019. An age-matched 1:5 comparison cohort was created from the general population of Ontario. Outcome measures were analysed from March 2020 to May 2022. The primary outcome was mental health service utilization, which included mental health-related visits to primary care providers, psychiatrists, mental health- and self-harm-related emergency department visits, and mental health hospitalizations. Mediation variables included ethnic concentration, residential instability, dependency, and material deprivation at the neighbourhood level and were derived from the Ontario Marginalization Index. RESULTS This study identified 2,085 transgender individuals from participating outpatient community and hospital clinics, who were matched to the general population (n = 10,425). Overall, neighbourhood-level marginalization did not clinically mediate mental health service use. However, transgender individuals were more likely to be exposed to all forms of neighbourhood-level marginalization, as well as having higher rates of health service use across all outcome measures. CONCLUSIONS In this study, mental health service use among transgender individuals was not clinically mediated by marginalization at the neighbourhood level. This study highlights the need to explore marginalization and mental health service use at the individual level to better understand the mental health disparities experienced by transgender individuals and to ensure that health-care services are inclusive and affirming.
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Affiliation(s)
- Alex Abramovich
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, Toronto, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - W. Ariel Gould
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Nelson Pang
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Claire de Oliveira
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, Toronto, Canada
- ICES University of Toronto, Mental Health and Addictions Research Program, Toronto, Canada
- Centre for Health Economics and Hull York Medical School, University of York, York, UK
| | - Tomisin Iwajomo
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
- ICES University of Toronto, Mental Health and Addictions Research Program, Toronto, Canada
| | - Myriam Vigny-Pau
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - June Sing Hong Lam
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada
- ICES University of Toronto, Mental Health and Addictions Research Program, Toronto, Canada
- General and Health Systems Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Canada
| | - Paul Kurdyak
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, Toronto, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada
- ICES University of Toronto, Mental Health and Addictions Research Program, Toronto, Canada
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Reddon H, Fairbairn N, Grant C, Milloy MJ. Experiencing homelessness and progression through the HIV cascade of care among people who use drugs. AIDS 2023; 37:1431-1440. [PMID: 37070552 PMCID: PMC10330029 DOI: 10.1097/qad.0000000000003570] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVE To investigate the longitudinal association between periods of homelessness and progression through the HIV cascade of care among people who use drugs (PWUD) with universal access to no-cost HIV treatment and care. DESIGN Prospective cohort study. METHODS Data were analysed from the ACCESS study, including systematic HIV clinical monitoring and a confidential linkage to comprehensive antiretroviral therapy (ART) dispensation records. We used cumulative link mixed-effects models to estimate the longitudinal relationship between periods of homelessness and progression though the HIV cascade of care. RESULTS Between 2005 and 2019, 947 people living with HIV were enrolled in the ACCESS study and 304 (32.1%) reported being homeless at baseline. Homelessness was negatively associated with overall progression through the HIV cascade of care [adjusted partial proportional odds ratio (APPO) = 0.56, 95% confidence interval (CI): 0.49-0.63]. Homelessness was significantly associated with lower odds of progressing to each subsequent stage of the HIV care cascade, with the exception of initial linkage to care. CONCLUSIONS Homelessness was associated with a 44% decrease in the odds of overall progression through the HIV cascade of care, and a 41-54% decrease in the odds of receiving ART, being adherent to ART and achieving viral load suppression. These findings support calls for the integration of services to address intersecting challenges of HIV, substance use and homelessness among marginalized populations such as PWUD.
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Affiliation(s)
- Hudson Reddon
- British Columbia Centre on Substance Use
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nadia Fairbairn
- British Columbia Centre on Substance Use
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - M-J Milloy
- British Columbia Centre on Substance Use
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Richardson L, Minh A, McCormack D, Laing A, Barbic S, Hayashi K, Milloy MJ, Huyser KR, Leahy K, Li J. Cohort Profile: The Assessing Economic Transitions (ASSET) Study-A Community-Based Mixed-Methods Study of Economic Engagement among Inner-City Residents. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191610456. [PMID: 36012091 PMCID: PMC9408769 DOI: 10.3390/ijerph191610456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 05/07/2023]
Abstract
The Assessing Economic Transitions (ASSET) study was established to identify relationships between economic engagement, health and well-being in inner-city populations given that research in this area is currently underdeveloped. This paper describes the objectives, design, and characteristics of the ASSET study cohort, an open prospective cohort which aims to provide data on opportunities for addressing economic engagement in an inner-city drug-using population in Vancouver, Canada. Participants complete interviewer-administered surveys quarterly. A subset of participants complete nested semi-structured qualitative interviews semi-annually. Between April 2019 and May 2022, the study enrolled 257 participants ages 19 years or older (median age: 51; 40% Indigenous, 11.6% non-Indigenous people of colour; 39% cis-gender women, 3.9% transgender, genderqueer, or two-spirit) and 41 qualitative participants. At baseline, all participants reported past daily drug use, with 27% currently using opioids daily, and 20% currently using stimulants daily. In the three months prior to baseline, more participants undertook informal income generation (75%) than formal employment (50%). Employed participants largely had casual jobs (42%) or jobs with part-time/varied hours (35%). Nested qualitative studies will focus on how inner-city populations experience economic engagement. The resulting evidence will inform policy and programmatic initiatives to address socioeconomic drivers of health and well-being.
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Affiliation(s)
- Lindsey Richardson
- Department of Sociology, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
- British Columbia Centre on Substance Use, 400-1045 Howe St., Vancouver, BC V6Z 2A9, Canada
- Correspondence:
| | - Anita Minh
- Department of Sociology, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
- British Columbia Centre on Substance Use, 400-1045 Howe St., Vancouver, BC V6Z 2A9, Canada
- Department of Epidemiology, University of Washington, Seattle, WA 98195, USA
| | - Deb McCormack
- British Columbia Centre on Substance Use, 400-1045 Howe St., Vancouver, BC V6Z 2A9, Canada
| | - Allison Laing
- Department of Sociology, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
- British Columbia Centre on Substance Use, 400-1045 Howe St., Vancouver, BC V6Z 2A9, Canada
| | - Skye Barbic
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, BC V6T 2B5, Canada
- Providence Research, 1190 Hornby, Vancouver, BC V6Z 2K5, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, 400-1045 Howe St., Vancouver, BC V6Z 2A9, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada
| | - M.-J. Milloy
- British Columbia Centre on Substance Use, 400-1045 Howe St., Vancouver, BC V6Z 2A9, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Kimberly R. Huyser
- Department of Sociology, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
| | - Kathleen Leahy
- UBC Learning Exchange, University of British Columbia, 612 Main St., Vancouver, BC V6A 2V3, Canada
| | - Johanna Li
- EMBERS Eastside Works, 57 E Hastings St., Vancouver, BC V6A 0A7, Canada
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Blumenkrans E, Hamilton J, Mohd Salleh NA, Kaida A, Small W, Barrios R, Milloy MJ. HIV and Incarceration: Implications for HIV-Positive People Who Use Illicit Drugs During a Seek, Test, Treat, and Retain Initiative in Canada. JOURNAL OF CORRECTIONAL HEALTH CARE 2022; 28:236-242. [PMID: 35758827 PMCID: PMC9529366 DOI: 10.1089/jchc.20.04.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
People who use illicit drugs (PWUD) face increased exposure to the criminal justice system and disproportionate burdens of HIV infection. This article investigated the effects of incarceration on HIV cascade of care-related measures in a setting with a community-wide seek, test, treat, and retain (STTR) initiative. Using a multivariable logistic regression analysis of 935 HIV-positive PWUD between 2005 and 2017, this article showed a negative relationship between periods of incarceration and two measures of engagement in clinical care for HIV among PWUD: recent dispensation of antiretroviral therapy and suppression of HIV viral load. These findings suggest the benefits of STTR-based efforts are limited by exposure to the criminal justice system and highlight the need for additional supports for PWUD with HIV exposed to the criminal justice system.
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Affiliation(s)
| | - Jonah Hamilton
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - N. A. Mohd Salleh
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Will Small
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Rolando Barrios
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.,Division of Social Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Address correspondence to: M-J Milloy, PhD, British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
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Mohd Salleh NA, Ahmad A, Vicknasingam B, Kamarulzaman A, Yahya 'A. Material Security Scale as a Measurement of Poverty among Key Populations At-Risk for HIV/AIDS in Malaysia: An Implication for People who Use Drugs and Transgender People during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19158997. [PMID: 35897368 PMCID: PMC9331958 DOI: 10.3390/ijerph19158997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 12/10/2022]
Abstract
The HIV epidemic is fueled by poverty; yet, methods to measure poverty remain scarce among populations at risk for HIV infection and disease progression to AIDS in Malaysia. Between August and November 2020, using data from a cross-sectional study of people who use drugs, (PWUD), transgender people, sex workers and men who have sex with men, this study examined the reliability and validity of a material security scale as a measurement of poverty. Additionally, we assessed factors associated with material security scores. We performed confirmatory factor analysis (CFA) for 268 study participants included in the analysis. A revised nine-item three-factor structure of the material security scale demonstrated an excellent fit in CFA. The revised material security score displayed good reliability, with Cronbach’s alpha of 0.843, 0.826 and 0.818 for housing, economic resources and basic needs factors, respectively. In a subsequent analysis, PWUD and transgender people were less likely to present good material security scores during the pandemic, compared to their counterparts. The revised nine-item scale is a useful tool to assess poverty among key populations at-risk for HIV/AIDS with the potential to be extrapolated in similar income settings.
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Affiliation(s)
- Nur Afiqah Mohd Salleh
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia;
- Centre of Excellence of Research in AIDS, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia; (A.A.); (A.K.)
| | - Ahsan Ahmad
- Centre of Excellence of Research in AIDS, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia; (A.A.); (A.K.)
- Yale School of Medicine, Yale University, New Heven, CT 06510, USA
| | | | - Adeeba Kamarulzaman
- Centre of Excellence of Research in AIDS, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia; (A.A.); (A.K.)
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - 'Abqariyah Yahya
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia;
- Correspondence: ; Tel.: +603-7967-4756
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Estimating the minimum antiretroviral adherence required for plasma HIV-1 RNA viral load suppression among people living with HIV who use unregulated drugs. AIDS 2022; 36:1233-1243. [PMID: 35833680 DOI: 10.1097/qad.0000000000003234] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Owing to advances in antiretroviral therapy (ART), we re-examined minimum ART adherence levels necessary to achieve sustained HIV-1 viral load (VL) suppression among people with HIV who use drugs (PHIV-PWUD). DESIGN AND METHODS We used data from ACCESS, a community-recruited prospective cohort of PHIV-PWUD in Vancouver, Canada. We calculated adherence using the proportion of days of ART dispensed in the year before each VL measurement. We used generalized linear mixed-effects models to identify adherence- and ART regimen-related correlates of VL suppression (<200 copies/ml). We employed probit regression models and generated dose-response curves to estimate the minimum adherence level needed to produce VL suppression in 90% of measures, stratified by regimen and calendar-year. RESULTS Among 837 ART-exposed PHIV-PWUD recruited between 1996 and 2017, the overall estimated adherence level necessary to achieve 90% VL suppression was 93% (95% confidence interval [CI]: 90-96). This differed by regimen: 69% (95% CI: 45-92) for integrase inhibitor (INSTI)-, 96% (95% CI: 92-100) for boosted protease inhibitor (bPI)-, and 98% (95% CI: 91-100) for non-nucleoside reverse transcriptase inhibitor-based regimens. In multivariable analysis, INSTI-based regimens were positively associated with VL suppression (vs. bPIs), while un-boosted PIs and other regimens were negatively associated. We observed a decreasing temporal trend of estimated adherence necessary for 90% VL suppression, dropping to 64% (95% CI: 50-77) during 2016-2017. CONCLUSION Although high levels of ART adherence were necessary to achieve consistent VL suppression, the minimum necessary adherence levels decreased over time. Overall, INSTI-based regimens performed the best, suggesting that they should be preferentially prescribed to PHIV-PWUD.
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7
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Mitra S, Grant C, Nolan S, Mohd Salleh NA, Milloy MJ, Richardson L. Assessing the Temporality Between Transitions onto Opioid Agonist Therapy and Engagement with Antiretroviral Therapy in a Cohort of HIV-Positive People Who Use Opioids Daily. AIDS Behav 2022; 26:1933-1942. [PMID: 34977956 PMCID: PMC9859621 DOI: 10.1007/s10461-021-03543-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 01/25/2023]
Abstract
A robust evidence-base describes the beneficial association between opioid agonist therapy (OAT) and HIV-related outcomes among people living with HIV and opioid use disorder. While some evidence suggests the stabilizing effect of OAT on antiretroviral therapy (ART) treatment engagement, less is understood about the potential for an inverse relationship. We sought to examine the relationship between transitions in ART engagement and transitions onto OAT. We used data from a prospective cohort of people living with HIV who use drugs in Vancouver, Canada-a setting with no-cost access to ART and low or no-cost access to OAT among low-income residents. Restricting the sample to those who reported daily or greater opioid use, we used generalized linear mixed-effects models to estimate the relationships between our primary outcome of transitions onto OAT (methadone or buprenorphine/naloxone) and transitions (1) onto ART and (2) into ART adherence. Subsequent analyses assessed the temporal sequencing of transitions. Between 2005 and 2017, among 433 participants, 48.3% reported transitioning onto OAT at least once. In concurrent analyses, transitions onto ART were positively and significantly associated with transitions onto OAT. Temporal sequencing revealed that transitions into OAT were also positively and significantly associated with subsequent transitions onto ART. OAT's potential to facilitate the uptake of ART points to the continued need to scale-up low-threshold, client-centered substance use services integrated alongside HIV care.
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Affiliation(s)
- Sanjana Mitra
- Interdisciplinary Graduate Studies Program, University of British Columbia, 270-2357 Main Mall, Vancouver, BC V6T 1Z4, Canada,British Columbia Centre on Substance Use, University of British Columbia, 400-1045 Howe, Vancouver, BC V6Z 2A9, Canada
| | - Cameron Grant
- British Columbia Centre on Substance Use, University of British Columbia, 400-1045 Howe, Vancouver, BC V6Z 2A9, Canada
| | - Seonaid Nolan
- British Columbia Centre on Substance Use, University of British Columbia, 400-1045 Howe, Vancouver, BC V6Z 2A9, Canada,Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
| | - Nur Afiqah Mohd Salleh
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia,Centre of Excellence for Research in AIDS, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - M.-J. Milloy
- British Columbia Centre on Substance Use, University of British Columbia, 400-1045 Howe, Vancouver, BC V6Z 2A9, Canada,Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
| | - Lindsey Richardson
- British Columbia Centre on Substance Use, University of British Columbia, 400-1045 Howe, Vancouver, BC V6Z 2A9, Canada,Department of Sociology, University of British Columbia, 6303 NW Marine Drive, Vancouver, BC V6T 1Z1, Canada
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Richardson L, Dong H, Kerr T, Milloy MJ, Hayashi K. Drug-related harm coinciding with income assistance payments: results from a community-based cohort of people who use drugs. Addiction 2021; 116:536-545. [PMID: 32621376 PMCID: PMC7779750 DOI: 10.1111/add.15182] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/02/2020] [Accepted: 06/29/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIMS Income assistance is critical to the health and wellbeing of socio-economically marginalized people who use illicit drugs (PWUD). However, past literature paradoxically identifies unintended increases in drug-related harm coinciding with synchronized payments that may magnify signals for drug use. The scope of such harm has not been fully characterized among non-institutionalized populations. This study examined socio-demographic, health and drug use-related correlates of payment-coincident drug-related harm. DESIGN This observational study uses data from prospective community-based longitudinal cohorts of PWUD between December 2013 and May 2018. SETTING Vancouver, British Columbia, Canada. PARTICIPANTS A total of 1604 PWUD receiving monthly income assistance. Our sample included 586 (36.5%) women, 861 (53.7%) non-white participants and 685 (42.7%) people living with HIV. MEASUREMENTS The primary outcome was a self-reported composite measure of drug-related harm in the past 6 months coinciding with income assistance, including higher-frequency substance use, non-fatal overdose and service barriers or interruptions. Subanalyses disaggregated this outcome. FINDINGS Payment-coincident drug-related harm was reported among 77.7% of participants during the study period. In multivariable models, key correlates positively and significantly associated with payment-coincident harm included: street-based income generation [adjusted odds ratio (aOR) = 1.48, 95% confidence interval (CI) = 1.26-1.74, P < 0.001], sex work (aOR = 1.66, 95% CI = 1.35-2.04, P < 0.001), illegal income generation (aOR = 1.57, 95% CI = 1.35-1.83 P < 0.001), homelessness (aOR = 1.34, 95% CI = 1.13-1.58, P < 0.001), exposure to violence (aOR = 1.31, 95% CI = 1.03-1.66, P = 0.032), daily crack cocaine use (aOR = 1.99, 95% CI = 1.59-2.50, P < 0.001), heavy alcohol use (aOR = 1.64, 95% CI = 1.37-1.97, P < 0.001) and injection drug use (aOR = 2.55, 95% CI = 2.01-3.23, P < 0.001). In subanalyses, specific harms were more likely among individuals reporting social, structural and health vulnerabilities. CONCLUSIONS In Vancouver, Canada, people who use illicit drugs who receive income assistance report high prevalence of payment-coincident drug-related harm, particularly people experiencing socioeconomic and structural marginalization or engaging in high-intensity drug use.
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Affiliation(s)
- Lindsey Richardson
- British Columbia Centre on Substance Use, Vancouver, BC, Canada,Department of Sociology, University of British Columbia, Vancouver, BC, Canada
| | - Huiru Dong
- British Columbia Centre on Substance Use, Vancouver, BC, Canada,Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, Vancouver, BC, Canada,Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, Vancouver, BC, Canada,Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, Vancouver, BC, Canada,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canad
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Jen Chiu YC, Conyers LM, Eissenstat SJ, Misrok M. Foundations for Living: Evaluation of an Integrated Employment and Housing Program for People Living With HIV. REHABILITATION COUNSELING BULLETIN 2020. [DOI: 10.1177/0034355220962175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Unstable housing and unemployment have been identified as major structural barriers to optimal HIV treatment outcomes among people living with HIV (PLWH). One solution is to provide integrated services that combine medical, employment, housing, and other psychosocial services to address the complex needs of PLWH. This program evaluation reports outcomes of the Foundations for Living program: an integrated employment and housing services program designed for PLWH. Employment and housing outcomes of participants who completed at least one 6-month reassessment were reported by frequency analysis. HIV immune health (CD4 count and viral load) are examined using a matched paired t test. HIV prevention outcomes were assessed by examining changes in the percent of participants with an undetectable viral load. Our findings indicate that among the participants who completed reassessments, 44.8% gained or maintained employment, 86.2% achieved viral load suppression, 75.9% achieved undetectable at the final reassessment. There was no statistical difference between the mean of CD4 count and viral load reported at intake and those reported during the final reassessment. Over half of the participants experienced unstable employment during the program, indicating that significant barriers to employment remain for this population. Implications for rehabilitation counseling practice and research are discussed.
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Affiliation(s)
| | | | | | - Mark Misrok
- National Working Positive Coalition, New York, USA
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10
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Mitra S, Boyd J, Wood E, Grant C, Milloy MJ, DeBeck K, Kerr T, Hayashi K. Elevated prevalence of self-reported unintentional exposure to fentanyl among women who use drugs in a Canadian setting: A cross-sectional analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 83:102864. [PMID: 32702611 PMCID: PMC7669704 DOI: 10.1016/j.drugpo.2020.102864] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/29/2020] [Accepted: 07/02/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND The United States and Canada are in the midst of an overdose epidemic, fueled by illicitly manufactured fentanyl. While marked differences in vulnerability to drug-related harm between men and women who use drugs is well characterized, the extent to which gender differences manifest in the present overdose crisis remains understudied. We examined differences in self-reported unintentional exposure to fentanyl between men and women who use drugs. METHODOLOGY Data were derived from three prospective cohorts of people who use drugs in Vancouver, Canada. Survey data were extracted on individuals who self-reported having used drugs known or believed to contain fentanyl in the past 30 days between December 2016 and November 2017. We used multivariable logistic regression (MLR) to examine the relationship between self-identified gender (woman vs. man) and self-reported unintentional exposure to fentanyl. As a sub-analysis, correlates of self-reported unintentional exposure to fentanyl were identified using MLR, stratified by gender. RESULTS Of 578 eligible participants, including 219 (37.9%) women, 200 (33.2%) perceived their exposure to fentanyl as unintentional (40.2% among women and 29.0% among men). In the MLR, being a woman was positively associated with self-reported unintentional fentanyl exposure (adjusted odds ratio = 2.11; 95% confidence interval: 1.45-3.09). Among women at least daily heroin use was negatively associated with self-reported unintentional fentanyl exposure, while perceiving a high or moderate risk of overdosing on fentanyl was positively associated with outcome. Among men older age was positively associated with self-reported unintentional fentanyl exposure, while injection drug use and at least daily heroin use was negatively associated with the outcome (all p<0.05). CONCLUSIONS Women were more than two times as likely to self-report they were unintentionally exposed to fentanyl compared to men. These findings highlight the urgent need to further understand experiences of gender-based risk differences and develop gender-focused interventions and policies aimed at preventing drug-related harm.
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Affiliation(s)
- Sanjana Mitra
- Interdisciplinary Graduate Studies Program, University of British Columbia, 270-2357 Main Mall, Vancouver, BC, V6T 1Z4 Canada; British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9 Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9 Canada; Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3 Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9 Canada; Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3 Canada
| | - Cameron Grant
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9 Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9 Canada; Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3 Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9 Canada; School of Public Policy, Simon Fraser University, 515 West Hastings Street #3271, BC, V6B 5K3 Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9 Canada; Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3 Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9 Canada; Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6 Canada.
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11
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Bloom BE, Jain S, Sun X, Garfein RS, Strathdee SA, Milloy MJ, Hayashi K, DeBeck K, Bluthenthal R, Werb D, Rafful C. Self-perception of assisting with future injection drug initiation: The influence of relationships in the process of drug injecting initiation. Drug Alcohol Rev 2020; 40:109-117. [PMID: 32840027 DOI: 10.1111/dar.13145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 07/01/2020] [Accepted: 07/12/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION AND AIMS People who inject drugs (PWID) play critical roles in assisting others into injection drug use (IDU) initiation. Understanding perceptions of PWID's risk of initiating others is needed to inform interventions for prevention. The objective was to examine factors associated with self-perception of assisting with future IDU initiation events. The primary variables of interest are the relationships of PWID with the person(s) they assisted and their reasons for previously providing initiation assistance. DESIGN AND METHODS Data from Preventing Injecting by Modifying Existing Responses, a multi-site prospective community-recruited cohort study, were analysed. Analyses were restricted to PWID who reported ever providing IDU initiation assistance. Site-specific (Vancouver, Canada [n = 746]; San Diego, USA [n = 95] and Tijuana, Mexico [n = 92]) multivariable logistic regression analyses were performed to determine factors associated with self-perception of assisting with future IDU initiation. RESULTS Having provided IDU initiation assistance to a family member or intimate partner decreased the odds of self-perception of assisting with future IDU initiation in Vancouver (AOR = 0.4; 95% CI 0.2-0.8); however, previous IDU initiation assistance to an 'other' increased the odds of self-perception of assisting with future IDU in Tijuana (AOR = 12.0; 95% CI 2.1-70.3). Daily IDU (Vancouver: AOR = 3.7; 95% CI 2.1-6.4) and less than daily IDU (San Diego: AOR = 5.9; 95% CI 1.3-27.1) (Vancouver: AOR = 2.6; 95% CI 1.4-2.9) were associated with increased self-perception of assisting with future IDU compared to current non-injectors. DISCUSSION AND CONCLUSIONS Relationship to past initiates and IDU frequency might increase PWID's self-perception of assisting with future IDU. Interventions focused on social support and reducing IDU frequency may decrease occurrences of IDU initiation assistance.
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Affiliation(s)
- Brittnie E Bloom
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, San Diego, USA.,Graduate School of Public Health, San Diego State University, San Diego, USA
| | - Sonia Jain
- Department of Family Medicine and Public Health, Biostatistics Research Center, University of California, San Diego, San Diego, USA
| | - Xiaoying Sun
- Department of Family Medicine and Public Health, Biostatistics Research Center, University of California, San Diego, San Diego, USA
| | - Richard S Garfein
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, San Diego, USA
| | - Steffanie A Strathdee
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, San Diego, USA
| | - M-J Milloy
- British Columbia Centre on Substance Use, Vancouver, Canada.,Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Kanna Hayashi
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Kora DeBeck
- Department of Medicine, University of British Columbia, Vancouver, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Ricky Bluthenthal
- Department of Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, USA
| | - Dan Werb
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, San Diego, USA.,Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada
| | - Claudia Rafful
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada.,Universidad Nacional Autónoma de México, Mexico City, Mexico.,Center on Global Mental Health Research, National Institute of Psychiatry, Mexico City, Mexico
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12
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Blumenkrans E, Socías ME, Richardson L, Kerr T, Shoveller J, Montaner J, Milloy MJ. Longitudinal Factors Associated with Used Syringe Lending Among HIV-Positive Antiretroviral Therapy-Naïve People Who Inject Drugs in a Canadian Setting. AIDS Behav 2020; 24:2163-2168. [PMID: 32026249 DOI: 10.1007/s10461-020-02781-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Sharing used syringes is an important route of HIV transmission, however, factors shaping used syringe-lending among antiretroviral therapy (ART)-naïve HIV-positive people who inject drugs (PWID) are not well-characterized. Multivariable logistic regression analyses using generalized estimating equations (GEE) were employed to investigate correlates of used syringe lending among ART-naïve PWID. Data was drawn from ACCESS, a prospective community-recruited cohort of HIV-positive illicit drug users in Vancouver, Canada, from 1996 to 2015. The analysis included 482 ART-naïve PWID, of which 116 (24.1%) reported ≥ 1 periods of used syringe lending. In longitudinal analyses, incarceration (Adjusted Odds Ratio [AOR] = 2.18, 95% Confidence Interval [CI] 1.48-3.20), daily cocaine injection (AOR= 1.97, 95% CI 1.33-2.90), and sex work (AOR = 1.61, 95% CI 1.02-2.55) during the 180-day observation period were positively associated with used syringe lending, while having a high school diploma (AOR = 0.63, 95% CI 0.43-0.93) and holding formal employment (AOR = 0.20, 95% CI 0.05-0.82) were negatively associated. We found a high prevalence of used syringe lending among ART-naïve HIV-positive PWID, particularly among those recently incarcerated, involved in sex work or who injected cocaine frequently. Conversely, markers of higher socio-economic status were negatively associated with used syringe lending. These findings highlight the critical need for policies and interventions to decrease socio-economic marginalization and criminalization among PWID living with HIV alongside the scale up of access to harm reduction services.
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13
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Material security and adherence to antiretroviral therapy among HIV-positive people who use illicit drugs. AIDS 2020; 34:1037-1045. [PMID: 32073444 DOI: 10.1097/qad.0000000000002501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the relationship between poverty, operationalized using a novel material security measure, and adherence to antiretroviral therapy (ART) among people who use illicit drugs (PWUD) in a context of universal access to HIV care. DESIGN We analyzed data from a community-recruited prospective cohort in Vancouver, Canada (n = 623), from 2014 to 2017. METHODS We used multivariable generalized mixed-effects analyses to estimate longitudinal factors associated with mean material security score. We then estimated the association between achieving at least 95% adherence to ART and overall mean material score, as well as mean score for three factors derived from a factor analysis. The three-factor structure, employed in the current analyses, were factor 1 (basic needs); factor 2 (housing-related variables) and factor 3 (economic resources). RESULTS Recent incarceration [β-coefficient (β) = -0.176, 95% confidence interval (95% CI): -0.288 to -0.063], unmet health needs [β = -0.110, 95% CI: -0.178 to -0.042), unmet social service needs (β = -0.264, 95% CI: -0.336 to -0.193) and having access to social services (β= -0.102, 95% CI: -0.1586 to -0.0465) were among the factors associated with lower material security scores. Contrary to expectations that low levels of material security in this population would lead to poor ART adherence, we did not observe a significant relationship between adherence and overall material security score, or for each factor individually. CONCLUSION Our findings highlight the potentially important role of no-cost, universal access to HIV prevention and treatment, in mitigating the impact of socioeconomic disadvantage on ART adherence.
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14
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ADAMS JW, MARSHALL BD, MOHD SALLEH NA, BARRIOS R, NOLAN S, MILLOY MJ. Receipt of opioid agonist treatment halves the risk of HIV-1 RNA viral load rebound through improved ART adherence for HIV-infected women who use illicit drugs. Drug Alcohol Depend 2020; 206:107670. [PMID: 31711873 PMCID: PMC7012150 DOI: 10.1016/j.drugalcdep.2019.107670] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 09/23/2019] [Accepted: 09/24/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Women living with HIV who use illicit drugs may be particularly vulnerable to HIV-1 RNA viral load (VL) rebound. METHODS We used longitudinal data from 2006 to 2017 to evaluate the impact of sociodemographic, behavioral, social-structural, and clinical factors on the hazard of viral rebound for women enrolled in the ACCESS study, a prospective cohort with systematic VL monitoring. Women were included if they achieved VL suppression (<50 copies/mL) following antiretroviral therapy (ART) initiation and had more than one study interview. Sociodemographic as well as substance use, social-structural, addiction treatment, and HIV clinical factors were evaluated as predictors of viral rebound (VL > 1000 copies/mL). Cox regressions using a recurrent events framework, time-varying covariates, robust standard errors, and a frailty component were used. RESULTS Of the 185 women included, 62 (34%) experienced at least one viral rebound event over an 11-year period, accumulating a total of 87 viral rebound events. In adjusted analysis, stimulant use more than doubled the hazard of viral rebound (adjusted hazard ratio [AHR]: 2.35, 95% confidence interval [CI]: 1.07-5.14) while the only factor protective against viral rebound was receipt of opioid agonist treatment (OAT) in the past six months (AHR: 0.46, 95% CI: 0.26-0.81). After adjusting for ART adherence in the past six months, the effect of OAT was attenuated (AHR: 0.57, 95% CI: 0.32-1.02). CONCLUSIONS Efforts to improve access to and retention within OAT programs and decrease stimulant use may improve rates of viral suppression for HIV-positive women who use illicit drugs.
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Affiliation(s)
- Joëlla W. ADAMS
- Brown University School of Public Health, Department of Epidemiology, 121 South Main Street, Providence, RI 02903, United States
| | - Brandon D.L. MARSHALL
- Brown University School of Public Health, Department of Epidemiology, 121 South Main Street, Providence, RI 02903, United States
| | - Nur Afiqah MOHD SALLEH
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada,Interdisciplinary Studies Graduate Program, University of British Columbia, 170-6371 Crescent Road, Vancouver, BC V6T 1Z2, Canada
| | - Rolando BARRIOS
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrad Street, Vancouver, BC V6Z 1Y6, Canada
| | - Seonaid NOLAN
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - M-J MILLOY
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada,Department of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, BC V5Z 1M9, Canada,Corresponding author: Address: British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, Canada, Tel: +1(604)806-9142, Fax: +1(604)806-9044,
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15
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Employment Cessation, Long Term Labour Market Engagement and HIV Infection Risk Among People Who Inject Drugs in an Urban Canadian Setting. AIDS Behav 2019; 23:3267-3276. [PMID: 30924066 DOI: 10.1007/s10461-019-02472-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The potential for changes in socio-economic status, such as employment exits, to increase HIV infection risk are not well examined among people who inject illicit drugs (PWID). We used longstanding cohort data from Vancouver, Canada, to longitudinally assess associations between employment cessation and outcomes with documented linkages to HIV infection risk among PWID. From 2005 to 2015, 1222 participants reported 1154 employment exits. Employment exits were significantly associated with transitions into unstable housing; moving to the inner-city; initiating informal, prohibited or illegal income generation; high risk drug use practices; and exiting methadone maintenance therapy. HIV infection rates were higher among participants with lower long-term labour market engagement. These findings suggest that employment cessation coincides with initiating exposure to aspects of socioeconomic marginalization and drug use associated with HIV infection risk. Support for employment retention that prevents poverty entrenchment and harmful drug use could contribute to HIV prevention measures for PWID.
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16
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Vandergrift GW, Gill CG. Paper spray mass spectrometry: A new drug checking tool for harm reduction in the opioid overdose crisis. JOURNAL OF MASS SPECTROMETRY : JMS 2019; 54:729-737. [PMID: 31432563 DOI: 10.1002/jms.4431] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/14/2019] [Accepted: 08/15/2019] [Indexed: 06/10/2023]
Abstract
Fentanyl and related psychoactive substances are at the forefront of the opioid overdose crisis, for which a complete solution is not immediately obvious. Drug testing for harm reduction may be an effective approach to both reduce overdoses and importantly, engage people who use drugs (PWUD) with the medical system. Paper spray mass spectrometry (PS-MS) is an ambient ionization strategy that is uniquely suited to address this complicated analytical task. This perspectives article presents the merits of PS-MS, with a focus upon the current state of its use as a candidate drug checking strategy for harm reduction. PS-MS is inherently sensitive and selective, with detection limits in the picogram range. It requires small drug samples (~1 mg) for quantitative drug testing, critical to encourage pre-consumption measurements by PWUD in the context of a harm reduction strategy. Calibrations obtained in surrogate drug matrices containing highly concentrated primary drugs demonstrate comparable sensitivities, a wide calibration range, and minimal matrix effects. PS-MS can be interfaced with high-resolution MS for non-targeted analysis, allowing the identification of novel psychoactive substances as they appear in street drugs. Individual quantitative PS-MS measurements for drug testing can be done in 1 minute or less, resulting in high sample throughput. Significant advancement in mass spectrometer miniaturization and mobilization has concomitant benefits for direct, on-site drug checking, such as reduced cost, simplified maintenance and ease of use by less skilled operators. While PS-MS technology continues to rapidly advance, it is our opinion that PS-MS can be utilized as an effective tool for harm reduction in the opioid overdose crisis.
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Affiliation(s)
- Gregory W Vandergrift
- Applied Environmental Research Laboratories (AERL), Chemistry Department, Vancouver Island University, Nanaimo, BC, Canada
- Chemistry Department, University of Victoria, Victoria, BC, Canada
| | - Chris G Gill
- Applied Environmental Research Laboratories (AERL), Chemistry Department, Vancouver Island University, Nanaimo, BC, Canada
- Chemistry Department, University of Victoria, Victoria, BC, Canada
- Chemistry Department, Simon Fraser University, Burnaby, BC, Canada
- Environmental and Occupational Health Sciences Department, University of Washington, Seattle, Washington
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17
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Mohd Salleh NA, Fairbairn N, Nolan S, Barrios R, Shoveller J, Richardson L, Milloy MJ. Dispensation of antiretroviral therapy and methadone maintenance therapy at the same facility in a low-barrier setting linked to optimal adherence to HIV treatment. HIV Med 2019; 20:606-614. [PMID: 31359615 DOI: 10.1111/hiv.12777] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2019] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- N A Mohd Salleh
- Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, BC, Canada.,BC Centre on Substance Use, Vancouver, BC, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - N Fairbairn
- BC Centre on Substance Use, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - S Nolan
- BC Centre on Substance Use, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - R Barrios
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada.,Vancouver Coastal Health, Vancouver, BC, Canada
| | - J Shoveller
- BC Centre on Substance Use, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - L Richardson
- BC Centre on Substance Use, Vancouver, BC, Canada.,Department of Sociology, University of British Columbia, Vancouver, BC, Canada
| | - M-J Milloy
- BC Centre on Substance Use, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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18
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Yeung B, Mohd Salleh NA, Socías E, Dong H, Shoveller J, Montaner JSG, Milloy MJS. Prevalence and Correlates of Reporting Difficulty Taking Antiretroviral Treatment Among HIV-Positive Illicit Drug Users in Vancouver, Canada: A Longitudinal Analysis. AIDS Behav 2019; 23:1250-1257. [PMID: 30284081 DOI: 10.1007/s10461-018-2271-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Bianca Yeung
- Faculty of Science, University of British Columbia, Vancouver, Canada
| | - N A Mohd Salleh
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Eugenia Socías
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Huiru Dong
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - J Shoveller
- Faculty of Science, University of British Columbia, Vancouver, Canada
| | - J S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - M-J S Milloy
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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19
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Boyd J, Richardson L, Anderson S, Kerr T, Small W, McNeil R. Transitions in income generation among marginalized people who use drugs: A qualitative study on recycling and vulnerability to violence. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 59:36-43. [PMID: 29986270 PMCID: PMC6167137 DOI: 10.1016/j.drugpo.2018.06.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 04/23/2018] [Accepted: 06/11/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND Income is an important determinant of health among people who use drugs (PWUD). However, understanding transitions between differing types of income generation within the formal and informal economy and how they can be shaped by vulnerability to risk and harm remain poorly understood. This study examines how transitions in income-generating activities are shaped by and influence exposure to violence among marginalised PWUD, in Vancouver, Canada's, Downtown Eastside (DTES) neighbourhood. METHODS Qualitative interviews were conducted with twenty-six individuals engaged in informal and illegal income-generating activities in the DTES. Interview transcripts were analyzed thematically, focusing on relationships between income generation and violence during the study period between January 2014 to April 2015 and drew upon concepts of social violence when interpreting these themes. RESULTS Participants' engagement in informal and illegal income-generating activities represented a means to negotiate survival given multiple barriers to formal employment and inadequate economic supports. Our findings highlight how informal and illegal income-generating activities in the DTES are characterized by structural, symbolic and everyday violence, while transitions from 'high risk' (e.g., sex work, drug dealing) to perceived 'low risk' (e.g., recycling) activities represent attempts to reduce exposure to violence. However, participants emphasized how informal income generation was nonetheless shaped by structural violence (e.g., gendered hierarchies and police harassment), experienced as everyday violence, and introduced exposure to alternate risks. CONCLUSION Our findings underscore the critical role of income generation in shaping exposure to violence, highlighting the need for low-threshold employment interventions targeting PWUD as a central component of harm reduction strategies.
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Affiliation(s)
- Jade Boyd
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Lindsey Richardson
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Sociology, University of British Columbia, Vancouver, BC, Canada
| | | | - Thomas Kerr
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Will Small
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada; Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Burnaby, BC, Canada
| | - Ryan McNeil
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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20
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Socias ME, Milloy MJ. Substance Use and Adherence to Antiretroviral Therapy: What Is Known and What Is Unknown. Curr Infect Dis Rep 2018; 20:36. [PMID: 30066113 DOI: 10.1007/s11908-018-0636-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW People who use drugs face multiple challenges to achieve optimal HIV treatment outcomes. This review discusses the current knowledge in substance use and antiretroviral therapy adherence, highlighting recent findings and potential interventions. RECENT FINDINGS Studies continue to demonstrate the negative impacts of substance use and related disorders on antiretroviral therapy adherence, with the exception of cannabis. Evidence-based addiction treatment, in particular, opioid agonist therapy, appears to improve adherence levels. Most individual-level adherence specific interventions did not provide sustained effects, and no studies evaluating structural-level interventions were found. Findings suggest the urgent need to scale-up opioid agonist therapy, as well as to simultaneously address multiple structural barriers to care to optimize HIV treatment outcomes among people who use drugs.
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Affiliation(s)
- M Eugenia Socias
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,Department of Medicine, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada. .,Department of Medicine, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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21
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Social and structural factors associated with greater time with a plasma HIV-1 RNA viral load above log10(1500) copies/ml among illicit drug users. AIDS 2018; 32:1059-1067. [PMID: 29424782 DOI: 10.1097/qad.0000000000001777] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Although previous cross-sectional studies have identified correlates of detectable plasma HIV-1 RNA viral load (VL) among HIV-positive people who use drugs (PWUD), longitudinal factors associated with heightened HIV transmission potential have not been well described. Therefore, we longitudinally examined factors associated with amount of person-time spent above log10(1500) copies/ml plasma among HIV-positive PWUD in Vancouver, Canada. DESIGN Data were derived from a long-running prospective cohort of HIV-positive PWUD linked to comprehensive clinical records including systematic VL monitoring. METHODS We used generalized estimating equations modeling to longitudinally examine factors associated with person-time (in days) with a VL more than log10(1500) copies/ml plasma in the previous 180 days. RESULTS Between December 2005 and May 2014, 845 PWUD were eligible and included in the study. Participants spent an average of 26.8% of observation time with a VL more than log10(1500) copies/ml. In multivariable analyses, homelessness (Adjusted Rate Ratio [ARR] = 1.45) and lack of social support (ARR = 1.27) were positively associated with person-time with a VL more than log10(1500) copies/ml. Older age (ARR = 0.97) and enrolment in addiction treatment (ARR = 0.75) were negatively associated with the outcome in multivariable analyses (all P < 0.05). CONCLUSION Social and structural factors, including periods of homelessness or lacking in social support, were independently associated with greater amount of time with heightened HIV transmission potential. These findings suggest the need for targeted efforts to address modifiable contextual factors that contribute to increased risk of onward HIV transmission among PWUD.
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22
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Bardwell G, Anderson S, Richardson L, Bird L, Lampkin H, Small W, McNeil R. The perspectives of structurally vulnerable people who use drugs on volunteer stipends and work experiences provided through a drug user organization: Opportunities and limitations. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 55:40-46. [PMID: 29501928 PMCID: PMC7046180 DOI: 10.1016/j.drugpo.2018.02.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 12/02/2017] [Accepted: 02/12/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND While drug user organizations (DUO) have received public health attention as a means to potentially reduce the harms associated with drug use, there is a lack of research on the compensation and structural forces that promote or inhibit participation in DUO. Against the backdrop of structural vulnerability experienced by people who use drugs (PWUD), we examined the impact of monetary 'volunteer stipends' provided through a DUO and explore their role in providing low-threshold employment opportunities and shaping participation in DUO. METHODS Participants were purposively sampled to reflect a range of perspectives and experiences volunteering at Vancouver Area Network of Drug Users (VANDU) and receiving stipends. Semi-structured qualitative interviews were conducted with 23 members of VANDU. Interview transcripts were coded in Atlas.ti 7 for key a priori themes and emergent categories from the data and analyzed thematically. RESULTS Stipends provided participants with symbolic and material recognition of the time, effort, and expertise they contribute to the organization, and functioned to facilitate ongoing participation. Payments that rewarded, skills, labour and drug-related knowledge reduced participant's perception of stigma against PWUD. Paid work in VANDU further provided participants with non-material benefits commonly attributed to regular employment, including social connections and a sense of purpose. Participants also identified the low level of pay as a limitation of VANDU's paid participation program. The daily demands of survival (accessing shelter, food, and drugs) posed more complex structural vulnerabilities to participate in VANDU, as small stipends were not sufficient to address these needs. CONCLUSION Low threshold employment opportunities within DUO may provide significant individual and public health benefits. However, these benefits are constrained by the small size of stipends. Therefore, to ensure better inclusion of PWUD, our findings recommend the development and expansion of equitable, accessible, well-paying employment programs for PWUD.
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Affiliation(s)
- Geoff Bardwell
- British Columbia Centre on Substance Use, 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.
| | - Solanna Anderson
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Lindsey Richardson
- British Columbia Centre on Substance Use, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada; Department of Sociology, University of British Columbia, 6303 NW Marine Drive, Vancouver, BC, V6T 1Z1, Canada
| | - Lorna Bird
- Vancouver Area Network of Drug Users, 380 East Hastings Street, Vancouver, BC, V6A 1P4, Canada
| | - Hugh Lampkin
- Vancouver Area Network of Drug Users, 380 East Hastings Street, Vancouver, BC, V6A 1P4, Canada
| | - Will Small
- British Columbia Centre on Substance Use, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 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
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Conyers LM, Richardson LA, Datti PA, Koch LC, Misrok M. A Critical Review of Health, Social, and Prevention Outcomes Associated With Employment for People Living With HIV. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2017; 29:475-490. [PMID: 29068719 DOI: 10.1521/aeap.2017.29.5.475] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
A growing need has emerged among HIV service providers, policymakers, and researchers to understand ways in which employment, as a key social determinant of health, can be leveraged toward improved health outcomes among people living with HIV (PLHIV) and the prevention of HIV transmission. This critical review summarizes and assesses current research related to (a) the employment needs and challenges among populations disproportionately impacted by HIV, (b) the relationship between employment and important health outcomes associated with the HIV Care Continuum, and (c) implications for policy, service provision, and future research. As a first step to deepening an understanding of these issues, this analysis identifies gaps in knowledge to underscore the need and direction for future research so that well-targeted interventions can be designed and evaluated and more responsive policies can be developed to address the public health implications of the vocational development and employment needs of PLHIV.
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Affiliation(s)
- Liza M Conyers
- Pennsylvania State University, University Park, Pennsylvania
| | | | | | | | - Mark Misrok
- National Working Positive Coalition, New York, New York
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Abstract
PURPOSE OF REVIEW The purpose is to describe and understand the sociodemographic determinants of survival in people living with HIV within high-income countries in the context of the current recommendation of universal antiretroviral therapy for all HIV-infected persons, irrespective of their CD4 cell count. RECENT FINDINGS Survival rates in people living with HIV have experienced remarkable increases in the last decade because of more efficacious and well tolerated treatments. Still, these improvements are unevenly distributed between regions across the world as well as within regions. HIV outcomes are heavily influenced by what are known as the 'social determinants' of health which have traditionally encompassed the gender, race/ethnicity, and socioeconomic axes. The evidence that these social determinants are now more important than before (more and earlier interventions are now available), has become stronger in the last 2 years. SUMMARY Because antiretroviral therapy is now recommended for all HIV-infected persons, sociodemographic factors limiting access to testing, treatment, and retention in care will undoubtedly jeopardize the UNAIDS aspirational objective to end AIDS by 2030. Innovative interventions targeting individuals with social vulnerability are urgently needed to ensure that social inequalities do not continue to be linked with higher mortality.
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Lake S, Kerr T, Capler R, Shoveller J, Montaner J, Milloy MJ. High-intensity cannabis use and HIV clinical outcomes among HIV-positive people who use illicit drugs in Vancouver, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 42:63-70. [PMID: 28336000 DOI: 10.1016/j.drugpo.2017.02.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 02/03/2017] [Accepted: 02/24/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Reforms to the legal status of medical and non-medical cannabis are underway in many jurisdictions, including Canada, as are renewed efforts to scale-up HIV treatment-as-prevention (TasP) initiatives. It has been suggested that high-intensity cannabis use may be associated with sub-optimal HIV treatment outcomes. Thus, using data from a setting with a community-wide treatment-as-prevention (TasP) initiative coinciding with increasing access to medical cannabis, we sought to investigate the possible impact of high-intensity cannabis use on HIV clinical outcomes. METHODS Data was derived from the ACCESS study, a prospective cohort of HIV-positive people who use illicit drugs (PWUD) in Vancouver, Canada. Cohort data was confidentially linked to comprehensive clinical profiles, including records of all antiretroviral therapy (ART) dispensations and longitudinal plasma HIV-1 RNA viral load (VL) monitoring. We used generalized estimating equations (GEEs) to estimate the longitudinal bivariable and multivariable relationships between at least daily cannabis use and two key clinical outcomes: overall engagement in ART care, and achieving a non-detectable VL among ART-exposed participants. RESULTS Between December 2005 and June 2015, 874 HIV-positive PWUD (304 [35%] non-male) were included in this study. In total, 788 (90%) were engaged in HIV care at least once over the study period, of whom 670 (85%) achieved non-detectable VL at least once. In multivariable analyses, ≥ daily cannabis use did not predict lower odds of ART care (Adjusted Odds Ratio [AOR]: 1.02, 95% confidence interval [CI]: 0.77-1.36) or VL non-detectability among ART-exposed (AOR: 0.96, 95% CI: 0.75-1.21). Upon testing for potential interactions, ≥ daily cannabis use was found to be negatively associated with ART engagement during periods of binge alcohol use (p<0.05). CONCLUSION With the exception of frequent cannabis use during periods of binge alcohol use, our results showed no statistically significant impact of daily cannabis use on the likelihood of ART care or VL non-detectability among ART-exposed HIV-positive PWUD. These findings are reassuring in light of the impending legalization of cannabis in Canada and ongoing efforts to expand TasP initiatives.
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Affiliation(s)
- Stephanie Lake
- 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, 2206 East Mall, Vancouver, BC V6T 1Z3, 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
| | - Rielle Capler
- Interdisciplinary Studies Graduate Program, University of British Columbia, 270-2357 Main Mall, Vancouver, BC V6T 1Z4, Canada
| | - Jeannie Shoveller
- 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, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Julio Montaner
- 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
| | - M-J Milloy
- 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.
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Methadone maintenance therapy and viral suppression among HIV-infected opioid users: The impacts of crack and injection cocaine use. Drug Alcohol Depend 2016; 168:211-218. [PMID: 27701042 PMCID: PMC5257247 DOI: 10.1016/j.drugalcdep.2016.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Methadone maintenance therapy (MMT) is associated with improved HIV treatment outcomes among people who use drugs (PWUD). The extent to which these benefits are sustained in the context of ongoing cocaine use is unclear. We assessed differential impacts of MMT on HIV viral load (VL) suppression in relation to discrete patterns of cocaine use. METHODS Data was drawn from ACCESS, a prospective cohort of HIV-positive PWUD in Vancouver, Canada. Generalized linear mixed-effects were used to model the independent effect of MMT on VL suppression across strata of frequency of cocaine injection and crack smoking (≥daily versus <daily), after adjustment for confounders. RESULTS The analysis included 397 HIV-positive opioid users who completed ≥1 study interview between 2005 and 2014. At baseline, 304 (77%) reported participation in MMT, 37 (9%) ≥daily cocaine injection, and 158 (40%) ≥daily crack smoking. In adjusted analyses, MMT remained independently associated with increased odds of VL suppression in both strata of crack smokers (AOR=3.11, 95% CI: 1.86-5.21 and AOR=1.48, 95%CI: 1.04-2.09, for ≥daily and <daily smokers, respectively), and among <daily cocaine injectors (AOR=1.88, 95%CI 1.38-2.56), but not among ≥daily cocaine injectors (AOR=1.37, 95%CI 0.53-3.49). Longer retention on MMT was positively associated with VL suppression in all strata of cocaine injection and crack smoke. CONCLUSIONS Exposure to MMT was associated with increased odds of VL suppression among HIV- positive opioid users regardless of crack use. However, this beneficial effect of MMT was lost among frequent cocaine injectors with shorter retention on MMT.
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Richardson L, Laing A, Milloy MJ, Maynard R, Nosyk B, Marshall B, Grafstein E, Daly P, Wood E, Montaner J, Kerr T. Protocol of the impact of alternative social assistance disbursement on drug-related harm (TASA) study: a randomized controlled trial to evaluate changes to payment timing and frequency among people who use illicit drugs. BMC Public Health 2016; 16:668. [PMID: 27473400 PMCID: PMC4966816 DOI: 10.1186/s12889-016-3304-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 07/14/2016] [Indexed: 01/28/2023] Open
Abstract
Background Government social assistance payments seek to alleviate poverty and address survival needs, but their monthly disbursement may cue increases in illicit drug use. This cue may be magnified when assistance is disbursed simultaneously across the population. Synchronized payments have been linked to escalations in drug use and unintended but severe drug-related harms, including overdose, as well as spikes in demand for health, social, financial and police services. Methods/design The TASA study examines whether changing payment timing and frequency can mitigate drug-related harm associated with synchronized social assistance disbursement. The study is a parallel arm multi-group randomized controlled trial in which 273 participants are randomly allocated for six assistance cycles to a control or one of two intervention arms on a 1:1:1 basis. Intervention arm participants receive their payments: (1) monthly; or (2) semi-monthly, in each case on days that are not during the week when cheques are normally issued. The study partners with a community-based credit union that has developed a system to vary social assistance payment timing. The primary outcome is a 40 % increase in drug use during the 3 days beginning with cheque issue day compared to other days of the month. Bi-weekly follow-up interviews collect participant information on this and secondary outcomes of interest, including drug-related harm (e.g. non-fatal overdose), exposure to violence and health service utilization. Self-reported data will be supplemented with participant information from health, financial, police and government administrative databases. A longitudinal, nested, qualitative parallel process evaluation explores participant experiences, and a cost-effectiveness evaluation of different disbursement scenarios will be undertaken. Outcomes will be compared between control and intervention arms to identify the impacts of alternative disbursement schedules on drug-related harm resulting from synchronized income assistance. Discussion This structural RCT benefits from strong community partnerships, highly detailed outcome measurement, robust methods of randomization and data triangulation with third party administrative databases. The study will provide evidence regarding the potential importance of social assistance program design as a lever to support population health outcomes and service provision for populations with a high prevalence of substance use. Trial registration NCT02457949 Registered 13 May 2015.
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Affiliation(s)
- Lindsey Richardson
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver V6Z 7Y6, BC, Canada
| | - Allison Laing
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver V6Z 7Y6, BC, Canada
| | - M-J Milloy
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver V6Z 7Y6, BC, Canada; Faculty of Medicine, Division of AIDS, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver V6Z 1Y6, BC, Canada
| | - Russ Maynard
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver V6Z 7Y6, BC, Canada; PHS Community Services Society, 20 Hastings Street W, Vancouver V6B 1G6, BC, Canada
| | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver V6Z 7Y6, BC, Canada; Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby V5A1S6, BC, Canada
| | - Brandon Marshall
- Department of Epidemiology, School of Public Health, Brown University, 121 South Main Street, Providence 02912, RI, USA
| | - Eric Grafstein
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, 910 West 10th Ave, Vancouver V5Z 1 M9, BC, Canada
| | - Patricia Daly
- Vancouver Coastal Health, 601 West Broadway, Vancouver V5Z 4C2, BC, Canada
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver V6Z 7Y6, BC, Canada; Faculty of Medicine, Division of AIDS, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver V6Z 1Y6, BC, Canada
| | - Julio Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver V6Z 7Y6, BC, Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver V6Z 7Y6, BC, Canada
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