The opioid crisis is driving mortality among under-served people living with HIV in British Columbia, Canada

Dynamics of overdose and non-overdose mortality among people living with HIV amidst the illicit drug toxicity crisis in British Columbia

We sought to characterize overdose and non-overdose mortality among PLWH amidst the illicit drug toxicity crisis in British Columbia, Canada. A population-based analysis of PLWH (age ≥19) in British Columbia accessing healthcare from April 1996 to March 2017 was conducted using data from the Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS) cohort linkage. Underlying causes of deaths were stratified into overdose and non-overdose causes. We compared (bivariate analysis) health-related characteristics and prescription history between PLWH died of overdose and non-overdose causes between April 2009 and March 2017. Among 9,180 PLWH, we observed 962 deaths (142 [14.7%] overdoses; 820 [85.2%] other causes). Compared to those who died from other causes, those who died of overdose were significantly younger (median age [Q, Q3]: 46 years [42, 52] vs. 54 years [48, 63]); had an indication of chronic pain (35.9% vs. 27.1%) and hepatitis C virus (64.8% vs. 50.4%), but fewer experienced hospitalization in the year before death. PLWH who died were most likely to be prescribed with opioids (>50%) and least likely with opioid agonist therapy (<10%) in a year before death. These findings highlight the syndemic of substance use, HCV, and chronic pain, and how the crisis is unqiuely impacting females and younger people.

Prevalence, correlates, and quality-of-life outcomes of major or persistent pain among women living with HIV in Metro Vancouver, Canada

While women living with HIV (WLWH) are twice as likely to report severe or undertreated chronic pain compared to men, little is known about pain among WLWH. Our goal was to characterize the correlates of pain as well as its impact on quality-of-life outcomes among women enrolled in the Sexual Health and HIV/AIDS Women's Longitudinal Needs Assessment (SHAWNA), an open longitudinal study of WLWH accessing care in Metro Vancouver, Canada. We conducted logistic regression analyses to identify associations between self-reported major or persistent pain with sociostructural and psychosocial correlates and with quality-of-life outcomes. Data are presented as adjusted odds ratios (aORs) with 95% confidence intervals. Among 335 participants, 77.3% reported pain at ≥ 1 study visit, with 46.3% experiencing any undiagnosed pain and 53.1% managing pain with criminalized drugs. In multivariable analysis, age (aOR 1.04[1.03-1.06] per year increase), food and housing insecurity (aOR 1.54[1.08-2.19]), depression diagnosis (aOR 1.34[1.03-1.75]), suicidality (aOR 1.71[1.21-2.42]), and non-daily, non-injection opioid use (aOR 1.53[1.07-2.17]) were associated with higher odds of pain. Daily non-injection opioid use (aOR 0.46[0.22-0.96]) and health services access (aOR 0.63[0.44-0.91]) were associated with lower odds of pain. In separate multivariable confounder models, pain was associated with reduced odds of good self-rated health (aOR 0.64[0.48-0.84] and increased odds of health interference with social activities (aOR 2.21[1.63-2.99]) and general function (aOR 3.24[2.54-4.13]). In conclusion, most WLWH in our study reported major or persistent pain. Pain was commonly undiagnosed and associated with lower quality of life. We identified structural and psychosocial factors associated with pain in WLWH, emphasizing the need for low-barrier, trauma-informed, and harm reduction-based interventions.

Characterizing opioid agonist therapy uptake and factors associated with treatment retention among people with HIV in British Columbia, Canada

Accidental overdoses are now the leading cause of death among people with HIV (PWH) in British Columbia (BC). We examined the utilization and retention of opioid agonist therapy (OAT). Adult PWH (≥19 years) with ≥ 1 OAT dispensation in BC between 2008 and 2020 were included (n = 1,515). OAT treatment episodes were formed based on specific criteria for slow-release oral morphine (SROM), methadone, injectable OAT (iOAT), and buprenorphine/naloxone. Retention in treatment was defined as any episode lasting ≥ 12 months. Logistic regression with generalized estimating equations modeled retention-associated factors. There was a 56.6% decline in OAT retention over time. Buprenorphine treatment exhibited significantly lower odds of retention (OR: 0.58; 95% CI: 0.36-0.92) compared to methadone. Conversely, no significant change in retention odds was observed for SROM (0.72; 0.33-1.54) and iOAT (0.81; 0.31-2.12). Factors associated with increased odds of retention included a 10-year increase in age (1.69; 1.46-1.95), previous retention history (1.96; 1.40-2.73), achieving OAT therapeutic dose (8.22; 6.67-10.14), and suppressed HIV viral load (1.35; 1.10-1.67). Individuals with a lifetime HCV diagnosis receiving iOAT were more likely to retain (3.61; 1.20-10.83). Each additional year on OAT during the study period was associated with a 4% increase in the odds of retention. A significant proportion of PWH had a history of OAT prescribing but experienced low retention rates. Retention outcomes were more positive for SROM and iOAT. The association between OAT medication type and retention odds may be particularly influenced by HCV diagnosis. Optimal management of opioid use disorder among PWH, with an emphasis on attaining the therapeutic dose is crucial.

HIV Vulnerability Among Survival Sex Workers Through Sexual Violence and Drug Taking in a Qualitative Study From Victoria, Canada, With Additional Implications for Pre-exposure Prophylaxis for Sex Workers

Objective: This qualitative study investigates how social and structural forces mediate vulnerability to HIV infection and transmission among survival sex workers, their clients, and their non-commercial, intimate partners-with especial focus on sexual violence and drug taking. Method: I employed an adapted grounded theory approach to conducting and analyzing (n = 9) open-ended, in-depth interviews with a convenience sample of currently working (and recently exited) survival sex workers from a community setting in Victoria, Canada. Findings: Participants revealed important contexts and conditions under which they were vulnerable to HIV infection. At the behavioural level, participants were aware of how HIV could be transmitted (condomless sex and sharing drug equipment), yet participants voiced strongly how structural and systemic features (for instance, client violence, the need for drugs, and "bad date" referrals) could squeeze and constrain their agency to take up safer practices, mediating their optimal HIV health and safety. Some participants reported strained relationships with police because of previous drug involvement. Conclusion: Survival sex workers constitute a health population vulnerable to HIV infection, and ensuring there could be a supportive (outreach) community replete with HIV resources is paramount. The availability of safer sex and drug equipment play important roles in HIV behavioural prevention efforts. However, uptake of pre-exposure prophylaxis (PrEP) at no cost in the Canadian province of British Columbia could be an important and beneficial structural intervention for non-injection drug taking cis-female sex workers in this study who are presently ineligible for no cost PrEP.