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Craig-Neil A, Ho J, Perri M, Gaspar M, Hunter C, Rachlis B, Kendall CE, Rueda S, Burchell AN, Pinto AD. Healthcare system action on employment as a social determinant of health in people living with HIV: A qualitative study. PLoS One 2023; 18:e0282421. [PMID: 37023048 PMCID: PMC10079099 DOI: 10.1371/journal.pone.0282421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 02/14/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Employment is a key social determinant of health. People living with HIV (PLWH) have higher unemployment rates than the general population. Vocational rehabilitation services have been shown to have significant and positive impact on employment status for PLWH. Understanding whether integrating vocational rehabilitation with health care services is acceptable, from the perspectives of PLWH and their health care providers, is an area that is understudied. METHODS We conducted a qualitative study and collected data from focus groups and interviews to understand the perspectives of stakeholders regarding the potential for vocational rehabilitation and health care integration. We completed five focus groups with 45 health care providers and one-to-one interviews with 23 PLWHs. Participants were sampled from infectious disease, primary care clinics, and AIDS Service Organizations in Toronto and Ottawa, Canada. Interviews were audio-recorded and transcribed. We conducted a reflexive thematic analysis of the transcripts. FINDINGS We found health care providers have little experience assisting patients with employment and PLWH had little experience receiving employment interventions from their health care team. This lack of integration between health care and vocational services was related to uncertainties around drug coverage, physician role and living with an episodic disability. Health care providers thought that there is potential for a larger role for health care clinics in providing employment interventions for PLWH however patients were divided. Some PLWH suggest that health care providers could provide advice on the disclosure of status, work limitations and act as advocates with employers. INTERPRETATION Health care providers and some PLWH recognize the importance of integrating health services with vocational services but both groups have little experience with implementing these types of interventions. Thus, there needs to be more study of such interventions, including the processes entailed and outcomes they aim to achieve.
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Affiliation(s)
- Amy Craig-Neil
- Li Ka Shing Knowledge Institute, Upstream Lab, MAP/Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
| | - Julia Ho
- Li Ka Shing Knowledge Institute, Upstream Lab, MAP/Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
| | - Melissa Perri
- Li Ka Shing Knowledge Institute, Upstream Lab, MAP/Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Mark Gaspar
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Charlotte Hunter
- Faculty of Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada
| | - Beth Rachlis
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - Claire E Kendall
- ICES, Toronto, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
- Bruyère Research Institute, Ottawa, Canada
- Institut du Savoir Montfort, Montfort Hospital, Ottawa, Canada
| | - Sergio Rueda
- Institute for Mental Health Policy Research and Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Ann N Burchell
- Li Ka Shing Knowledge Institute, MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Faculty of Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada
| | - Andrew D Pinto
- Li Ka Shing Knowledge Institute, Upstream Lab, MAP/Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Faculty of Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada
- University of Toronto Practice-Based Research Network, Toronto, Canada
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Chambers C, Gillis J, Lindsay J, Benoit AC, Kendall CE, Kroch A, Grewal R, Loutfy M, Mah A, O'Brien K, Ogilvie G, Raboud J, Rachlis A, Rachlis B, Yeung A, Yudin MH, Burchell AN. Low human papillomavirus vaccine uptake among women engaged in HIV care in Ontario, Canada. Prev Med 2022; 164:107246. [PMID: 36075492 DOI: 10.1016/j.ypmed.2022.107246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/08/2022] [Accepted: 09/02/2022] [Indexed: 10/31/2022]
Abstract
Women living with HIV are at higher risk for human papillomavirus (HPV)-related dysplasia and cancers and thus are prioritized for HPV vaccination. We measured HPV vaccine uptake among women engaged in HIV care in Ontario, Canada, and identified socio-demographic, behavioural, and clinical characteristics associated with HPV vaccination. During annual interviews from 2017 to 2020, women participating in a multi-site, clinical HIV cohort responded to a cross-sectional survey on HPV vaccine knowledge and receipt. We used logistic regression to derive age-adjusted odds ratios and 95% confidence intervals (CI) for factors associated with self-reported vaccine initiation (≥1 dose) or series completion (3 doses). Among 591 women (median age = 48 years; interquartile range = 40-56 years), 13.2% (95%CI = 10.5-15.9%) had received ≥1 dose. Of those vaccinated, 64.6% had received 3 doses. Vaccine initiation (≥1 dose) was significantly higher among women aged 20-29 years at 31.0% but fell to 13.9% in those aged 30-49 years and < 10% in those aged ≥50 years. After age adjustment, vaccine initiation was significantly associated with being employed (vs. unemployed but seeking work), income $40,000-$59,999 (vs. <$20,000), being married/common-law (vs. single), living with children, immigrating to Canada >5 years ago (vs. immigrating ≤5 years ago), never smoking (vs. currently smoking), and being in HIV care longer (per 10 years). Similar factors were identified for series completion (3 doses). HPV vaccine uptake remains low among women living with HIV in our cohort despite regular engagement in care. Recommendations for improving uptake include education of healthcare providers, targeted community outreach, and public funding of HPV vaccination.
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Affiliation(s)
- Catharine Chambers
- University of Toronto, Toronto, Canada; St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | | | - Joanne Lindsay
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Anita C Benoit
- University of Toronto, Toronto, Canada; Women's College Research Institute, Toronto, Canada
| | - Claire E Kendall
- Bruyère Research Institute, Ottawa, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Canada; ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada
| | - Abigail Kroch
- University of Toronto, Toronto, Canada; Ontario HIV Treatment Network, Toronto, Canada; Public Health Ontario, Toronto, Canada
| | - Ramandip Grewal
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada; Public Health Ontario, Toronto, Canada
| | - Mona Loutfy
- Women's College Research Institute, Toronto, Canada
| | - Ashley Mah
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | | | - Gina Ogilvie
- University of British Columbia, Vancouver, Canada
| | - Janet Raboud
- University of Toronto, Toronto, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | | | - Beth Rachlis
- University of Toronto, Toronto, Canada; ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada
| | - Anna Yeung
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Mark H Yudin
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Ann N Burchell
- University of Toronto, Toronto, Canada; St. Michael's Hospital, Unity Health Toronto, Toronto, Canada.
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Choi BCK, King AS, Graham K, Bilotta R, Selby P, Harvey BJ, Gupta N, Morris SK, Young E, Buklis P, Reynolds DL, Rachlis B, Upshur R. Clinical public health: harnessing the best of both worlds in sickness and in health. Health Promot Chronic Dis Prev Can 2022; 42:440-444. [PMID: 36223159 PMCID: PMC9584176 DOI: 10.24095/hpcdp.42.10.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Effective, sustained collaboration between clinical and public health professionals can lead to improved individual and population health. The concept of clinical public health promotes collaboration between clinical medicine and public health to address complex, real-world health challenges. In this commentary, we describe the concept of clinical public health, the types of complex problems that require collaboration between individual and population health, and the barriers towards and applications of clinical public health that have become evident during the COVID-19 pandemic. RATIONALE The focus of clinical medicine on the health of individuals and the aims of public health to promote and protect the health of populations are complementary. Interdisciplinary collaborations at both levels of health interventions are needed to address complex health problems. However, there is a need to address the disciplinary, cultural and financial barriers to achieving greater and sustained collaboration. Recent successes, particularly during the COVID-19 pandemic, provide a model for such collaboration between clinicians and public health practitioners. CONCLUSION A public health approach that fosters ongoing collaboration between clinical and public health professionals in the face of complex health threats will have greater impact than the sum of the parts.
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Affiliation(s)
- Bernard C K Choi
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Public Health Agency of Canada, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Arlene S King
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn Graham
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto/London, Ontario, Canada
| | - Rose Bilotta
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Peter Selby
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto/London, Ontario, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bart J Harvey
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Neeru Gupta
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Ophthalmology and Vision Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada
| | - Shaun K Morris
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric Young
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Pierrette Buklis
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Donna L Reynolds
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Beth Rachlis
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Ross Upshur
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
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Rachlis B, Qu K, Seidel J, Zhao Y, Gagnon R, Kioke S, Innes E, Ho M, Victor C, Ratnasingham S, Walker JD, Loon L. Weeneebayko Area Health Authority-ICES-Laurentian University Collaboration: Working together to support communities with Indigenous Health Research in the James and Hudson Bay Region, in Northeast Ontario, Canada. Int J Popul Data Sci 2022. [PMCID: PMC9645097 DOI: 10.23889/ijpds.v7i3.2086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Smylie J, McConkey S, Rachlis B, Avery L, Mecredy G, Brar R, Bourgeois C, Dokis B, Vandevenne S, Rotondi MA. Uncovering SARS-COV-2 vaccine uptake and COVID-19 impacts among First Nations, Inuit and Métis Peoples living in Toronto and London, Ontario. CMAJ 2022; 194:E1018-E1026. [PMID: 35918087 PMCID: PMC9481260 DOI: 10.1503/cmaj.212147] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 11/14/2022] Open
Abstract
Background: First Nations, Inuit and Métis Peoples across geographies are at higher risk of SARS-CoV-2 infection and COVID-19 because of high rates of chronic disease, inadequate housing and barriers to accessing health services. Most Indigenous Peoples in Canada live in cities, where SARS-CoV-2 infection is concentrated. To address gaps in SARS-CoV-2 information for these urban populations, we partnered with Indigenous agencies and sought to generate rates of SARS-CoV-2 testing and vaccination, and incidence of infection for First Nations, Inuit and Métis living in 2 Ontario cities. Methods: We drew on existing cohorts of First Nations, Inuit and Métis adults in Toronto (n = 723) and London (n = 364), Ontario, who were recruited using respondent-driven sampling. We linked to ICES SARS-CoV-2 databases and prospectively monitored rates of SARS-CoV-2 testing, diagnosis and vaccination for First Nations, Inuit and Métis, and comparator city and Ontario populations. Results: We found that SARS-CoV-2 testing rates among First Nations, Inuit and Métis were higher in Toronto (54.7%, 95% confidence interval [CI] 48.1% to 61.3%) and similar in London (44.5%, 95% CI 36.0% to 53.1%) compared with local and provincial rates. We determined that cumulative incidence of SARS-CoV-2 infection was not significantly different among First Nations, Inuit and Métis in Toronto (7364/100 000, 95% CI 2882 to 11 847) or London (7707/100 000, 95% CI 2215 to 13 200) compared with city rates. We found that rates of vaccination among First Nations, Inuit and Métis in Toronto (58.2%, 95% CI 51.4% to 64.9%) and London (61.5%, 95% CI 52.9% to 70.0%) were lower than the rates for the 2 cities and Ontario. Interpretation: Although Ontario government policies prioritized Indigenous populations for SARS-CoV-2 vaccination, vaccine uptake was lower than in the general population for First Nations, Inuit and Métis Peoples in Toronto and London. Ongoing access to culturally safe testing and vaccinations is urgently required to avoid disproportionate hospital admisson and mortality related to COVID-19 in these communities.
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Affiliation(s)
- Janet Smylie
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont.
| | - Stephanie McConkey
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Beth Rachlis
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Lisa Avery
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Graham Mecredy
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Raman Brar
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Cheryllee Bourgeois
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Brian Dokis
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Stephanie Vandevenne
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
| | - Michael A Rotondi
- Well Living House (Smylie, McConkey, Brar), St. Michael's Hospital; Dalla Lana School of Public Health (Smylie, McConkey, Rachlis, Avery), University of Toronto; ICES (Smylie, Rachlis, Mecredy); Princess Margaret Cancer Centre (Avery), University Health Network; Seventh Generations Midwives Toronto (Bourgeois); Call Auntie Clinic (Bourgeois); School of Kinesiology and Health Science (Rotondi), York University, Toronto, Ont.; Southwest Ontario Aboriginal Health Access Centre (Dokis, Vandevenne), London, Ont
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Choi B, Pakes B, Bilotta R, Graham K, Gupta N, King AS, Dimaras H, Wei X, Gibson B, Reynolds DL, Morris SK, Selby P, Harvey BJ, Fox AL, Rachlis B, Bhuiyan S, Nnorom O, Upshur R. Defining Clinical Public Health. CLIN INVEST MED 2021; 44:E71-76. [PMID: 34152710 DOI: 10.25011/cim.v44i2.36479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE To solve complex health issues, an innovative and multidisciplinary framework is necessary. The Clinical Public Health (CPH) Division was established at the University of Toronto (UofT), Canada to foster inte-gration of primary care, preventive medicine and public health in education, practice and research. To better understand how the construct of CPH might be applied, we surveyed clinicians, researchers and public health professionals affiliated with the CPH Division to assess their understanding of the CPH concept and its utility in fostering broad collaboration. METHODS A two-wave anonymous survey of the active faculty of the CPH Division, UofT was conducted across Canada. Wave 1 participants (n = 187; 2016) were asked to define CPH, while Wave 2 participants (n = 192; 2017) were provided a synthesis of Wave 1 results and asked to rank each definition. Both waves were asked about the need for a common definition, and to comment on CPH. RESULTS Response rates for the first and second waves were 25% and 22%, respectively. Of the six definitions of CPH from Wave 1, "the intersection of clinical practice and public health," was most highly ranked by Wave 2 participants. Positive perceptions of CPH included multidisciplinary collaboration, new fields and insights, forward thinking and innovation. Negative perceptions included CPH being a confusing term, too narrow in scope or too clinical. CONCLUSION The concept of Clinical Public Health can foster multidisciplinary collaboration to address com-plex health issues because it provides a useful framework for bringing together key disciplines and diverse professional specialties.
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Affiliation(s)
- Bernard Choi
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; Public Health Agency of Canada, Government of Canada, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Canada; Injury Prevention Research Center, Shantou University Medical College, Shantou, Guangdong, China.
| | - Barry Pakes
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, ON, Canada
| | - Rose Bilotta
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | - Kathryn Graham
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto/London, ON, Canada; National Drug Research Institute, Curtin University, Perth, Western Australia, Australia
| | - Neeru Gupta
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; Department of Ophthalmology and Vision Sciences, Faculty of Medicine, University of Toronto, ON, Canada; Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, ON, Canada
| | - Arlene S King
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | - Helen Dimaras
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; Department of Ophthalmology and Vision Sciences, Faculty of Medicine, University of Toronto, ON, Canada; Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences Program and Centre for Global Child Health, Sick-Kids Research Institute, Toronto, ON, Canada
| | - Xiaolin Wei
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | - Brian Gibson
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | - Donna L Reynolds
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, ON, Canada
| | - Shaun K Morris
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; Department of Pediatrics, Faculty of Medicine, University of Toronto, ON, Canada; Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
| | - Peter Selby
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto/London, ON, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, ON, Canada
| | - Bart J Harvey
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | - Ann L Fox
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; Department of Human Nutrition, St. Francis Xavier University, Antigonish, NS, Canada
| | - Beth Rachlis
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; ICES, Toronto, Ontario, ON, Canada
| | - Shafi Bhuiyan
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; School of Occupational and Public Health and the Chang School of Continuing Education, Ryerson University, Toronto, ON, Canada
| | - Onye Nnorom
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, ON, Canada
| | - Ross Upshur
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON, Canada; Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, ON, Canada; Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
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Rachlis B, Candido E, Shapiro H, Ishiguro L, Kwong J. Prevalence of Blood-Borne Viral Infections (HIV, HBV, HCV) Among People Seeking Fertility Services in Ontario, Canada. Int J Popul Data Sci 2020. [DOI: 10.23889/ijpds.v5i5.1466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
IntroductionThe Applied Health Research Question (AHRQ) portfolio is an initiative funded by the Ontario Ministry of Health. Knowledge users submit AHRQ requests to use administrative health data to inform their planning, policy and program development.
Objectives and ApproachA request to estimate prevalence and incidence of blood-borne viral infections (BBVI) among individuals seeking fertility treatment services was approved by the ICES AHRQ team. To determine whether current BBVI testing guidelines are effective for timely identification of BBVI among individuals undergoing fertility treatment, this AHRQ sought to estimate: a) the testing prevalence for BBVI (using viral hepatitis as a proxy for all BBVI including HIV), and b) BBVI incidence over a five-year follow-up period. We used infertility codes billed by gynecologists and urologists to identify individuals seeking fertility treatment between April 1, 2002 and March 31, 2013. We looked forward five years from a first BBVI test billed by a physician and assessed annual and cumulative testing prevalence and incidence of viral hepatitis and HIV using rule-based administrative algorithms.
ResultsIn total, 184,328 individuals (61.6% female) were included. The five-year BBVI testing prevalence was 45.5% and the median number of tests was 2 (interquartile range: 2-3). An estimated 949 new cases (48% diagnosed within 12 months of first BBVI test) of viral hepatitis were identified in the five-year follow-up with a cumulative incidence of 522 (95%CI 489-556) per 100,000 population. There were 57 new HIV cases (68% diagnosed within 12 months of first BBVI test) with a cumulative incidence of 31.4 (95%CI 23.7-40.6) per 100,000. The median times from first BBVI test to hepatitis and HIV diagnoses were 13.0 months (IQR 2.33-32.2) and 3.0 months (IQR 1.34-20.0), respectively.
Conclusion / ImplicationsThese findings can be used to develop evidence-based BBVI testing guidelines for individuals seeking fertility treatment services.
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Mbuagbaw L, Hajizadeh A, Wang A, Mertz D, Lawson DO, Smieja M, Benoit AC, Alvarez E, Puchalski Ritchie L, Rachlis B, Logie C, Husbands W, Margolese S, Zani B, Thabane L. Overview of systematic reviews on strategies to improve treatment initiation, adherence to antiretroviral therapy and retention in care for people living with HIV: part 1. BMJ Open 2020; 10:e034793. [PMID: 32967868 PMCID: PMC7513605 DOI: 10.1136/bmjopen-2019-034793] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 07/01/2020] [Accepted: 08/07/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES We sought to map the evidence and identify interventions that increase initiation of antiretroviral therapy, adherence to antiretroviral therapy and retention in care for people living with HIV at high risk for poor engagement in care. METHODS We conducted an overview of systematic reviews and sought for evidence on vulnerable populations (men who have sex with men (MSM), African, Caribbean and Black (ACB) people, sex workers (SWs), people who inject drugs (PWID) and indigenous people). We searched PubMed, Excerpta Medica dataBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and the Cochrane Library in November 2018. We screened, extracted data and assessed methodological quality in duplicate and present a narrative synthesis. RESULTS We identified 2420 records of which only 98 systematic reviews were eligible. Overall, 65/98 (66.3%) were at low risk of bias. Systematic reviews focused on ACB (66/98; 67.3%), MSM (32/98; 32.7%), PWID (6/98; 6.1%), SWs and prisoners (both 4/98; 4.1%). Interventions were: mixed (37/98; 37.8%), digital (22/98; 22.4%), behavioural or educational (9/98; 9.2%), peer or community based (8/98; 8.2%), health system (7/98; 7.1%), medication modification (6/98; 6.1%), economic (4/98; 4.1%), pharmacy based (3/98; 3.1%) or task-shifting (2/98; 2.0%). Most of the reviews concluded that the interventions effective (69/98; 70.4%), 17.3% (17/98) were neutral or were indeterminate 12.2% (12/98). Knowledge gaps were the types of participants included in primary studies (vulnerable populations not included), poor research quality of primary studies and poorly tailored interventions (not designed for vulnerable populations). Digital, mixed and peer/community-based interventions were reported to be effective across the continuum of care. CONCLUSIONS Interventions along the care cascade are mostly focused on adherence and do not sufficiently address all vulnerable populations.
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Affiliation(s)
- Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Centre for the Develoment of Best Practices in Health, Yaounde Central Hospital, Yaounde, Cameroon
| | - Anisa Hajizadeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Annie Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Daeria O Lawson
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Rheumatology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Marek Smieja
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anita C Benoit
- Women's College Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Alvarez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
| | - Lisa Puchalski Ritchie
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Beth Rachlis
- Division of Clinical Public Health, Dalla Lana School of Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Carmen Logie
- Women's College Research Institute, Toronto, Ontario, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | | | - Shari Margolese
- Canadian HIV Trials Network Community Advisory Committee, Vancouver, British Columbia, Canada
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town Lung Institute, Rondebosch, Western Cape, South Africa
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Pediatrics and Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Centre for Evaluation of Medicine, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
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Rachlis B, Nam S, Rosenes R, Santoni T, Peck R, Betts A, Kendall C, Yoong D, Sharp A, Gauvin H, Goddard L, Owino M, Rourke SB, Antoniou T. Using concept mapping to explore the challenges associated with affording and accessing medications among people living with HIV in Ontario, Canada. AIDS Care 2020; 33:827-832. [PMID: 32490685 DOI: 10.1080/09540121.2020.1770182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Antiretroviral medications are expensive, and people living with HIV often experience challenges accessing and paying for medication due to various obstacles. We used concept mapping to explore the challenges people living with HIV in Ontario, Canada, face when accessing medication. In brainstorming, 68 participants generated 447 statements in response to the focus prompt "Some people living with HIV have trouble getting and paying for prescription drugs because … ". These were consolidated into 77 statements, which were sorted (n = 30) and rated (n = 32) on importance and commonality. A ten-cluster concept map consisting of individual- and health system-related clusters was generated. Clusters included: (1) Stigma, (2) Medication-Related Issues, (3) Individual Challenges, (4) Basic Needs, (5) Immigration, (6) Coverage, (7) Trillium Drug Program, (8) Access to Services, (9) System-Level Issues and (10) Access to Professional Services. Statements in Coverage and Basic Needs were rated most important and common although there was variability by Ontario residence and drug coverage mechanisms. Strategies to address challenges were generated in Interpretation (n = 25 participants). Given that continuous access to antiretroviral therapy is necessary to fully realize treatment benefits, policies and interventions that address these challenges are needed.
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Affiliation(s)
- Beth Rachlis
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Seungwon Nam
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Ron Rosenes
- Canadian HIV/AIDS Legal Network, Toronto, Canada
| | | | - Ryan Peck
- HIV & AIDS Legal Clinic Ontario (HALCO), Toronto, Canada
| | - Adrian Betts
- The AIDS Committee of Durham Region, Oshawa, Canada
| | - Claire Kendall
- Bruyère Research Institute, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Deborah Yoong
- Department of Pharmacy, St. Michael's Hospital, Toronto, Canada
| | | | | | | | - Maureen Owino
- Committee for Accessible AIDS Treatment (CAAT), Toronto, Canada
| | - Sean B Rourke
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Tony Antoniou
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada
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- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Liu J, Wilton J, Sullivan A, Marchand-Austin A, Rachlis B, Giles M, Light L, Sider D, Kroch AE, Gilbert M. Cohort profile: Development and profile of a population-based, retrospective cohort of diagnosed people living with HIV in Ontario, Canada (Ontario HIV Laboratory Cohort). BMJ Open 2019; 9:e027325. [PMID: 31133591 PMCID: PMC6537973 DOI: 10.1136/bmjopen-2018-027325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE Population-based cohorts of diagnosed people living with HIV (PLWH) are limited worldwide. In Ontario, linked HIV diagnostic and viral load (VL) test databases are centralised and contain laboratory data commonly used to measure engagement in HIV care. We used these linked databases to create a population-based, retrospective cohort of diagnosed PLWH in Ontario, Canada. PARTICIPANTS A datamart was created by integrating diagnostic and VL databases and linking records at the individual level. These databases contain information on laboratory test results and sociodemographic/clinical information collected on requisition/surveillance forms. Datamart individuals enter our cohort with the first record of a nominal HIV-positive diagnostic test (1985-2015) or VL test (1996-2015), and remain unless administratively lost to follow-up (LTFU; no VL test for >2 years and no VL test in later years). Non-nominal diagnostic tests are excluded as they lack identifying information to permit linkage to other tests. However, individuals diagnosed non-nominally are included in the cohort with record of a VL test. The LTFU rule is applied to indirectly censor for death/out-migration. FINDINGS TO DATE As of the end of 2015, the datamart contained 40 372 HIV-positive diagnostic tests and 23 851 individuals with ≥1 VL test. Almost half (46.3%) of the diagnostic tests were non-nominal and excluded, although this was lower (~15%) in recent years. Overall, 29 587 individuals have entered the cohort-contributing 229 302 person-years of follow-up since 1996. Between 2000 and 2015, the number of diagnosed PLWH (cohort individuals not LTFU) increased from 8859 to 16 110, and the percent who were aged ≥45 years increased from 29.1% to 62.6%. The percent of diagnosed PLWH who were virally suppressed (<200 copies/mL) increased from 40.7% in 2000 to 79.5% in 2015. FUTURE PLANS We plan to conduct further analyses of HIV care engagement and link to administrative databases with information on death, migration, physician billing claims and prescriptions. Linkage to other data sources will address cohort limitations and expand research opportunities.
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Affiliation(s)
- Juan Liu
- Public Health Ontario, Toronto, Ontario, Canada
| | - James Wilton
- Ontario HIV Treatment Network, Toronto, Ontario, Canada
| | | | | | - Beth Rachlis
- Ontario HIV Treatment Network, Toronto, Ontario, Canada
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Madison Giles
- Division of Social and Behavioural Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Lucia Light
- Ontario HIV Treatment Network, Toronto, Ontario, Canada
| | - Doug Sider
- Public Health Ontario, Toronto, Ontario, Canada
| | - Abigail E Kroch
- Public Health Ontario, Toronto, Ontario, Canada
- Ontario HIV Treatment Network, Toronto, Ontario, Canada
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Mark Gilbert
- Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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11
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Mitra S, Rachlis B, Krysowaty B, Marshall Z, Olsen C, Rourke S, Kerr T. Potential use of supervised injection services among people who inject drugs in a remote and mid-size Canadian setting. BMC Public Health 2019; 19:284. [PMID: 30849946 PMCID: PMC6408761 DOI: 10.1186/s12889-019-6606-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 02/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While supervised injection services (SIS) feasibility research has been conducted in large urban centres across North America, it is unknown whether these services are acceptable among people who inject drugs (PWID) in remote, mid-size cities. We assessed willingness to use SIS and expected frequency of SIS use among PWID in Thunder Bay, a community in Northwestern, Ontario, Canada, serving people from suburban, rural and remote areas of the region. METHODS Between June and October 2016, peer research associates administered surveys to PWID. Sociodemographic characteristics, drug use and behavioural patterns associated with willingness to use SIS and expected frequency of SIS use were estimated using bivariable and multivariable logistic regression models. Design preferences and amenities identified as important to provide alongside SIS were assessed descriptively. RESULTS Among 200 PWID (median age, IQR: 35, 28-43; 43% female), 137 (69%) reported willingness to use SIS. In multivariable analyses, public injecting was positively associated with willingness to use (Adjusted Odds Ratio (AOR): 4.15; 95% confidence interval (CI): 2.08-8.29). Among those willing to use SIS, 87 (64%) said they would always/usually use SIS, while 48 (36%) said they would sometime/occasionally use SIS. In multivariable analyses, being female (AOR: 2.44; 95% CI: 1.06-5.65) and reporting injecting alone was positively associated with higher expected frequency of use (AOR: 2.59; 95% CI: 1.02-6.58). CONCLUSIONS Our findings suggest that SIS could play a role in addressing the harms of injection drug use in remote and mid-sized settings particularly for those who inject in public, as well as women and those who inject alone, who report higher expected frequency of SIS use. Design preferences of local PWID, in addition to differences according to gender should be taken into consideration to maximize the uptake of SIS, alongside existing health and social service provisions available to PWID.
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Affiliation(s)
- Sanjana Mitra
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,Interdisciplinary Studies Graduate Program, University of British Columbia, 270-2357 Main Mall, H.R. MacMillan Building, Vancouver, BC, V6T 1Z4, Canada
| | - Beth Rachlis
- Institute for Clinical and Evaluative Sciences, 2075 Bayview Avenue, G172, Toronto, ON, M4N 3M5, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON, M5T 3M7, Canada
| | - Bonnie Krysowaty
- Lakehead Social Planning Council, #38-125 Syndicate Avenue South, Thunder Bay, ON, P7E 6H8, Canada
| | - Zack Marshall
- School of Social Work, McGill University, 3506 University Street, Room 300, Montreal, QC, H3A 2A7, Canada
| | - Cynthia Olsen
- Thunder Bay Drug Strategy, City of Thunder Bay, 500 Donald Street East, P.O. Box 800, Thunder Bay, ON, P7C 2K4, Canada
| | - Sean Rourke
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 209 Victoria Street, 3rd Floor, Toronto, ON, M5B 1T8, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, 8th Floor, Toronto, ON, M5T 1R8, 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, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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12
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Desir FA, Lesko CR, Moore RD, Horberg MA, Wong C, Crane HM, Silverberg M, Thorne JE, Rachlis B, Rabkin C, Mayor AM, Mathews WC, Althoff KN. One Size Fits (n)One: The Influence of Sex, Age, and Sexual Human Immunodeficiency Virus (HIV) Acquisition Risk on Racial/Ethnic Disparities in the HIV Care Continuum in the United States. Clin Infect Dis 2019; 68:795-802. [PMID: 30169624 PMCID: PMC6376102 DOI: 10.1093/cid/ciy556] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/13/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The United States National HIV/AIDS Strategy established goals to reduce disparities in retention in human immunodeficiency virus (HIV) care, antiretroviral therapy (ART) use, and viral suppression. The impact of sex, age, and sexual HIV acquisition risk (ie, heterosexual vs same-sex contact) on the magnitude of HIV-related racial/ethnic disparities is not well understood. METHODS We estimated age-stratified racial/ethnic differences in the 5-year restricted mean percentage of person-time spent in care, on ART, and virally suppressed among 19 521 women (21.4%), men who have sex with men (MSM; 59.0%), and men who have sex with women (MSW; 19.6%) entering HIV care in the North American AIDS Cohort Collaboration on Research and Design between 2004 and 2014. RESULTS Among women aged 18-29 years, whites spent 12.0% (95% confidence interval [CI], 1.1%-20.2%), 9.2% (95% CI, .4%-20.4%), and 13.5% (95% CI, 2.7%-22.5%) less person-time in care, on ART, and virally suppressed, respectively, than Hispanics. Black MSM aged ≥50 years spent 6.3% (95% CI, 1.3%-11.7%), 11.0% (95% CI, 4.6%-18.1%), and 9.7% (95% CI, 3.6%-16.8%) less person-time in these stages, respectively, than white MSM ≥50 years of age. Among MSM aged 40-49 years, blacks spent 9.8% (95% CI, 2.4%-16.5%) and 11.9% (95% CI, 3.8%-19.3%) less person-time on ART and virally suppressed, respectively, than whites. CONCLUSIONS Racial/ethnic differences in HIV care persist in specific populations defined by sex, age, and sexual HIV acquisition risk. Clinical and public health interventions that jointly target these demographic factors are needed.
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Affiliation(s)
- Fidel A Desir
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Michael A Horberg
- Division of Research, Kaiser Permanente Mid-Atlantic Research Group, Rockville, Maryland
| | - Cherise Wong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Heidi M Crane
- Division of Allergy and Infectious Diseases, University of Washington, Seattle
| | | | - Jennifer E Thorne
- Division of Ocular Immunology, Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland
| | - Beth Rachlis
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Charles Rabkin
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Angel M Mayor
- Department of Internal Medicine, Universidad Central del Caribe, Bayamon, Puerto Rico
| | | | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore
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Orkin AM, McArthur A, Venugopal J, Kithulegoda N, Martiniuk A, Buchman DZ, Kouyoumdjian F, Rachlis B, Strike C, Upshur R. Defining and measuring health equity in research on task shifting in high-income countries: A systematic review. SSM Popul Health 2019; 7:100366. [PMID: 30886887 PMCID: PMC6402379 DOI: 10.1016/j.ssmph.2019.100366] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/16/2019] [Accepted: 01/23/2019] [Indexed: 12/25/2022] Open
Abstract
Introduction Task shifting interventions have been implemented to improve health and address health inequities. Little is known about how inequity and vulnerability are defined and measured in research on task shifting. We conducted a systematic review to identify how inequity and vulnerability are identified, defined and measured in task shifting research from high-income countries. Methods and analysis We implemented a novel search process to identify programs of research concerning task shifting interventions in high-income countries. We searched MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and CENTRAL to identify articles published from 2004 to 2016. Each program of research incorporated a "parent" randomized trial and "child" publications or sub-studies arising from the same research group. Two investigators extracted (1) study details, (2) definitions and measures of health equity or population vulnerability, and (3) assessed the quality of the reporting and measurement of health equity and vulnerability using a five-point scale developed for this study. We summarized the findings using a narrative approach. Results Fifteen programs of research met inclusion criteria, involving 15 parent randomized trials and 62 child publications. Included programs of research were all undertaken in the United States, among Hispanic- (5/15), African- (2/15), and Korean-Americans (1/15), and low socioeconomic status (2/15), rural (2/15) and older adult populations (2/15). Task shifting interventions included community health workers, peers, and a variety of other non-professional and lay workers to address a range of non-communicable diseases. Some research provided robust analyses of the affected populations' health inequities and demonstrated how a task shifting intervention redressed those concerns. Other studies provided no such definitions and measured only biomedical endpoints. Conclusion Included studies vary substantially in the definition and measurement of health inequity and vulnerability. A more precise theoretical and evaluative framework for task shifting is recommended to effectively achieve the goal of equitable health.
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Affiliation(s)
- Aaron M Orkin
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Allison McArthur
- Ontario Public Health Libraries Association, Toronto, ON, Canada
| | - Jeyasakthi Venugopal
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
| | - Natasha Kithulegoda
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada
| | - Alexandra Martiniuk
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,University of Sydney, Sydney, NSW, Australia.,George Institute for Global Health Australia, Sydney, NSW, Australia
| | - Daniel Z Buchman
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada.,Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Fiona Kouyoumdjian
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Beth Rachlis
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Ontario HIV Treatment Network, Toronto, ON, Canada.,Dignitas International, Toronto, ON, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ross Upshur
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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14
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Wilton J, Liu J, Sullivan A, Rachlis B, Marchand-Austin A, Giles M, Light L, Rank C, Burchell AN, Gardner S, Sider D, Gilbert M, Kroch AE. Trends in HIV care cascade engagement among diagnosed people living with HIV in Ontario, Canada: A retrospective, population-based cohort study. PLoS One 2019; 14:e0210096. [PMID: 30608962 PMCID: PMC6319701 DOI: 10.1371/journal.pone.0210096] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 12/16/2018] [Indexed: 01/22/2023] Open
Abstract
Background The HIV cascade is an important framework for assessing systems of care, but population-based assessment is lacking for most jurisdictions worldwide. We measured cascade indicators over time in a population-based cohort of diagnosed people living with HIV (PLWH) in Ontario, Canada. Methods We created a retrospective cohort of diagnosed PLWH using a centralized laboratory database with HIV diagnostic and viral load (VL) test records linked at the individual-level. Individuals enter the cohort with record of a nominal HIV-positive diagnostic test or VL test, and remain unless administratively lost to follow-up (LTFU, >2 consecutive years with no VL test and no VL test in later years). We calculated the annual percent of diagnosed PLWH (cohort individuals not LTFU) between 2000 and 2015 who were in care (≥1 VL test), on ART (as documented on VL test requisition) or virally suppressed (<200 copies/ml). We also calculated time from diagnosis to linkage to care and viral suppression among individuals newly diagnosed with HIV. Analyses were stratified by sex and age. Upper/lower bounds were calculated using alternative indicator definitions. Results The number of diagnosed PLWH increased from 8,859 (8,859–11,389) in 2000 to 16,110 (16,110–17,423) in 2015. Over this 16-year period, the percent of diagnosed PLWH who were: in care increased from 81% (63–81%) to 87% (81–87%), on ART increased from 55% (34–60%) to 81% (70–82%) and virally suppressed increased from 41% (23–46%) to 80% (67–81%). Between 2000 and 2014, the percent of newly diagnosed individuals who linked to care within three months of diagnosis or achieved viral suppression within six months of diagnosis increased from 67% to 82% and from 22% to 42%, respectively. Estimates were generally lower for females and younger individuals. Discussion HIV cascade indicators among diagnosed PLWH in Ontario improved between 2000 and 2015, but gaps still remain—particularly for younger individuals.
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Affiliation(s)
- James Wilton
- Data and Applied Science Impact, Ontario HIV Treatment Network, Toronto, Canada
| | - Juan Liu
- Public Health Ontario, Toronto, Canada
| | | | - Beth Rachlis
- Data and Applied Science Impact, Ontario HIV Treatment Network, Toronto, Canada
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Dignitas International, Toronto, Ontario, Canada
| | | | - Madison Giles
- Data and Applied Science Impact, Ontario HIV Treatment Network, Toronto, Canada
| | - Lucia Light
- Data and Applied Science Impact, Ontario HIV Treatment Network, Toronto, Canada
| | | | - Ann N. Burchell
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Canada
- Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sandra Gardner
- Baycrest Health Sciences, Toronto, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Mark Gilbert
- Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Abigail E. Kroch
- Data and Applied Science Impact, Ontario HIV Treatment Network, Toronto, Canada
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- * E-mail:
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Wilton J, Light L, Gardner S, Rachlis B, Conway T, Cooper C, Cupido P, Kendall CE, Loutfy M, McGee F, Murray J, Lush J, Rachlis A, Wobeser W, Bacon J, Kroch AE, Gilbert M, Rourke SB, Burchell AN. Late diagnosis, delayed presentation and late presentation among persons enrolled in a clinical HIV cohort in Ontario, Canada (1999-2013). HIV Med 2018; 20:110-120. [PMID: 30430742 DOI: 10.1111/hiv.12686] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Timely HIV diagnosis and presentation to medical care are important for treatment and prevention. Our objective was to measure late diagnosis, delayed presentation and late presentation among individuals in the Ontario HIV Treatment Network Cohort Study (OCS) who were newly diagnosed in Ontario. METHODS The OCS is a multi-site clinical cohort study of people living with HIV in Ontario, Canada. We measured prevalence of late diagnosis [CD4 count < 350 cells/μL or an AIDS-defining condition (ADC) within 3 months of HIV diagnosis], delayed presentation (≥ 3 months from HIV diagnosis to presentation to care), and late presentation (CD4 count < 350 cells/μL or ADC within 3 months of presentation). We identified characteristics associated with these outcomes and explored their overlap. RESULTS A total of 1819 OCS participants were newly diagnosed in Ontario from 1999 to 2013. Late diagnosis (53.0%) and presentation (54.0%) were common, and a quarter (23.1%) of participants were delayed presenters. In multivariable models, the participants of delayed presentation decreased over calendar time, but that of late diagnosis/presentation did not. Late diagnosis contributed to the majority (> 87%) of late presentation, and the prevalence of delayed presentation was similar among those diagnosed late versus early (13.4 versus 13.4%, respectively; P = 0.99). Characteristics associated with higher odds of late diagnosis/presentation in multivariable analyses included older age at diagnosis/presentation; African, Caribbean and Black race/ethnicity; Indigenous race/ethnicity; female sex; and being a male who did not report sex with men. There were lower odds of late diagnosis/presentation among participants who had ever injected drugs. In contrast, delayed presentation risk factors included younger age at diagnosis and having ever injected drugs. CONCLUSIONS Late presentation is common in Ontario, as it is in other high-income countries. Our findings suggest that efforts to reduce late presentation should focus on facilitating earlier diagnosis for the populations identified in this analysis.
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Affiliation(s)
- J Wilton
- Ontario HIV Treatment Network, Toronto, Canada
| | - L Light
- Ontario HIV Treatment Network, Toronto, Canada
| | - S Gardner
- Baycrest Health Sciences, Toronto, Canada.,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - B Rachlis
- Ontario HIV Treatment Network, Toronto, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - T Conway
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Canadian Positive People Network, Ottawa, Canada
| | - C Cooper
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - P Cupido
- Ontario HIV Treatment Network, Toronto, Canada
| | - C E Kendall
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - M Loutfy
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - F McGee
- AIDS Bureau, Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - J Murray
- AIDS Bureau, Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - J Lush
- AIDS Bureau, Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - A Rachlis
- Department of Medicine, University of Toronto, Toronto, Canada.,Sunnybrook Health Science Centre, Toronto, Canada
| | - W Wobeser
- Department of Molecular and Biomedical Sciences, Queen's University, Kingston, Canada.,Department of Public Health, Queen's University, Kingston, Canada
| | - J Bacon
- Ontario HIV Treatment Network, Toronto, Canada
| | - A E Kroch
- Ontario HIV Treatment Network, Toronto, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - M Gilbert
- Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - S B Rourke
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - A N Burchell
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.,Department of Family and Community Medicine, St Michael's Hospital, Toronto, Canada.,Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Yoong D, Bayoumi AM, Robinson L, Rachlis B, Antoniou T. Public prescription drug plan coverage for antiretrovirals and the potential cost to people living with HIV in Canada: a descriptive study. CMAJ Open 2018; 6:E551-E560. [PMID: 30482757 PMCID: PMC6276936 DOI: 10.9778/cmajo.20180058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Antiretrovirals are expensive and people living with HIV may experience a range of financial burdens when accessing these medications. Our aim was to describe the policy of all Canadian public drug insurance programs for antiretroviral drugs and illustrated how these policies might affect patients' annual out-of-pocket expenditures. METHODS In December 2017, we reviewed public drug programs offering antiretroviral coverage in Canada using government websites to summarize eligibility criteria. We estimated the annual out-of-pocket costs incurred by people living with HIV by applying the cost-sharing rules to 2 hypothetical cases, a single man and a married woman with a net household income of $39 000 and $80 000, respectively, receiving identical prescriptions in different jurisdictions. RESULTS We observed substantial variation in the subsidy provided based mainly on geography, income and age. All 5 federal programs and 6 of 13 provincial and territorial jurisdictions offered universal coverage. In the remaining regions, patients spend up to several thousand dollars annually depending on income (Manitoba), age and income (Ontario, Saskatchewan) and age, income and drug costs (Quebec and Newfoundland and Labrador). We found the greatest variation for our higher income case, with out-of-pocket expenses ranging from 0 to over 50% of the antiretroviral cost. INTERPRETATION There is considerable inter- and intra-jurisdiction heterogeneity in the cost-sharing policies for antiretrovirals across Canada's public drug programs. Policy reforms that either eliminate or set national standards for copayments, deductibles or premiums would minimize variation and could reduce the risk of cost-associated non-adherence to HIV therapy.
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Affiliation(s)
- Deborah Yoong
- Department of Pharmacy (Yoong), St. Michael's Hospital, Toronto, Ont.; Centre for Urban Health Solutions (Bayoumi), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Bayoumi), University of Toronto, Toronto, Ont.; Department of Pharmacy (Robinson), Windsor Regional Hospital, Windsor, Ont.; Ontario HIV Treatment Network (Rachlis), Toronto, Ont.; Department of Family and Community Medicine (Antoniou), St. Michael's Hospital and University of Toronto, Toronto, Ont.; Li Ka Shing Knowledge Institute (Antoniou), St. Michael's Hospital, Toronto, Ont.
| | - Ahmed M Bayoumi
- Department of Pharmacy (Yoong), St. Michael's Hospital, Toronto, Ont.; Centre for Urban Health Solutions (Bayoumi), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Bayoumi), University of Toronto, Toronto, Ont.; Department of Pharmacy (Robinson), Windsor Regional Hospital, Windsor, Ont.; Ontario HIV Treatment Network (Rachlis), Toronto, Ont.; Department of Family and Community Medicine (Antoniou), St. Michael's Hospital and University of Toronto, Toronto, Ont.; Li Ka Shing Knowledge Institute (Antoniou), St. Michael's Hospital, Toronto, Ont
| | - Linda Robinson
- Department of Pharmacy (Yoong), St. Michael's Hospital, Toronto, Ont.; Centre for Urban Health Solutions (Bayoumi), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Bayoumi), University of Toronto, Toronto, Ont.; Department of Pharmacy (Robinson), Windsor Regional Hospital, Windsor, Ont.; Ontario HIV Treatment Network (Rachlis), Toronto, Ont.; Department of Family and Community Medicine (Antoniou), St. Michael's Hospital and University of Toronto, Toronto, Ont.; Li Ka Shing Knowledge Institute (Antoniou), St. Michael's Hospital, Toronto, Ont
| | - Beth Rachlis
- Department of Pharmacy (Yoong), St. Michael's Hospital, Toronto, Ont.; Centre for Urban Health Solutions (Bayoumi), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Bayoumi), University of Toronto, Toronto, Ont.; Department of Pharmacy (Robinson), Windsor Regional Hospital, Windsor, Ont.; Ontario HIV Treatment Network (Rachlis), Toronto, Ont.; Department of Family and Community Medicine (Antoniou), St. Michael's Hospital and University of Toronto, Toronto, Ont.; Li Ka Shing Knowledge Institute (Antoniou), St. Michael's Hospital, Toronto, Ont
| | - Tony Antoniou
- Department of Pharmacy (Yoong), St. Michael's Hospital, Toronto, Ont.; Centre for Urban Health Solutions (Bayoumi), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Bayoumi), University of Toronto, Toronto, Ont.; Department of Pharmacy (Robinson), Windsor Regional Hospital, Windsor, Ont.; Ontario HIV Treatment Network (Rachlis), Toronto, Ont.; Department of Family and Community Medicine (Antoniou), St. Michael's Hospital and University of Toronto, Toronto, Ont.; Li Ka Shing Knowledge Institute (Antoniou), St. Michael's Hospital, Toronto, Ont
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17
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Mbuagbaw L, Mertz D, Lawson DO, Smieja M, Benoit AC, Alvarez E, Puchalski Ritchie L, Rachlis B, Logie C, Husbands W, Margolese S, Thabane L. Strategies to improve adherence to antiretroviral therapy and retention in care for people living with HIV in high-income countries: a protocol for an overview of systematic reviews. BMJ Open 2018; 8:e022982. [PMID: 30206089 PMCID: PMC6144485 DOI: 10.1136/bmjopen-2018-022982] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 08/17/2018] [Accepted: 08/20/2018] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION While access to antiretroviral therapy (ART) for people living with HIV has expanded in recent years, additional efforts are required to support adherence to medication and retention in care. Interventions should be applicable in real-world settings and amenable to widespread use. The objectives of this overview are to identify effective pragmatic interventions that increase adherence to ART and retention in care for people living with HIV at high risk for suboptimal adherence and retention in high-income countries. METHODS AND ANALYSIS We will conduct an overview of systematic reviews of studies on interventions which target improved adherence to medication and retention in care among high-risk people living with HIV in high-income countries (men who have sex with men, African, Caribbean and black people, sex workers, people who inject drugs, indigenous people and other socially marginalised groups). We will search the following databases: PubMed, EMBASE (Exerpta Medica Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, Web of Science and the Cochrane Library. We will conduct screening, data extraction and assessment of methodological quality of the systematic reviews. Analysis will be narrative. Our findings will be interpreted in light of the certainty of the evidence, level of pragmatism, setting and population of interest. ETHICS AND DISSEMINATION Only published secondary data will be used in this study, and therefore ethics approval is not required. Our findings will be disseminated as peer-reviewed manuscripts, conference abstracts and through community activities. The findings from this overview will inform a mixed-methods study among people living with HIV and health workers in Ontario, Canada.
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Affiliation(s)
- Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O’Sullivan Research Centre, St Joseph’s Healthcare, Hamilton, Ontario, Canada
- Centre for Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Dominik Mertz
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Daeria O Lawson
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Marek Smieja
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anita C Benoit
- Women’s College Research, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Alvarez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
| | - Lisa Puchalski Ritchie
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Beth Rachlis
- The Ontario HIV Treatment Network, Toronto, Ontario, Canada
- Dignitas International, Toronto, Ontario, Canada
- Division of Clinical Public Health, Dalla Lana School of Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Carmen Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | | | - Shari Margolese
- Canadian HIV Trials Network Community Advisory Committee, Toronto, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O’Sullivan Research Centre, St Joseph’s Healthcare, Hamilton, Ontario, Canada
- Departments of Paediatrics and Anaesthesia, McMaster University, Hamilton, Ontario, Canada
- Centre for Evaluation of Medicine, St Joseph’s Healthcare, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
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18
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Rachlis B, Light L, Gardner S, Burchell AN, Raboud J, Kendall C, McIsaac MA, Murray J, Rachlis A, Rourke SB. The impact of drug coverage on viral suppression among people living with HIV in Ontario, Canada. Can J Public Health 2018; 109:800-809. [PMID: 30140981 DOI: 10.17269/s41997-018-0104-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/25/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We investigated the effect of drug coverage on viral suppression (sVL) in Ontario, Canada, where there is no universal coverage of prescription drugs, including antiretroviral therapy (ART). METHODS Ontarians without employment coverage may be eligible for varying degrees of coverage through government-sponsored programs. Remaining individuals pay all expenses entirely out of pocket. Among participants on ART enrolled in the Ontario HIV Treatment Network Cohort Study (OCS) who were interviewed in 2008-2013 with known or imputable drug coverage, we estimated the prevalence with sVL (< 200 copies/mL) as of their last viral load each year. We calculated prevalence ratios (PR) according to time-updated socio-economic and behavioural factors using multivariable generalized estimating equations with a log-link function. Multiple imputation was used to assess the sensitivity of these findings to different assumed missing data models. RESULTS One thousand two hundred forty-seven participants were included (3463 person-years). Compared to study participants with employer coverage, individuals covered through the Ontario Drug Benefit (ODB) were less likely to be suppressed (PR, 95% confidence interval (CI) 0.96, 0.93-0.98). After multivariable adjustment, ODB remained independently associated with less success in achieving sVL (adjusted PR, 95% CI 0.98, 0.95-0.99). These findings were robust to different assumptions about the missing data. CONCLUSION Our findings suggest that drug coverage can affect viral suppression in our setting. Further research is needed to identify the mechanisms by which coverage interacts with individual patient factors to affect viral suppression. Mechanisms to improve access and coverage for ART are needed.
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Affiliation(s)
- Beth Rachlis
- The Ontario HIV Treatment Network, Toronto, 1300 Yonge Street, Toronto, Ontario, M4T 1X3, Canada. .,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Lucia Light
- The Ontario HIV Treatment Network, Toronto, 1300 Yonge Street, Toronto, Ontario, M4T 1X3, Canada
| | - Sandra Gardner
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Baycrest Health Sciences, Toronto, Ontario, Canada
| | - Ann N Burchell
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Janet Raboud
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Claire Kendall
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael A McIsaac
- Department of Public Health Sciences, Queens University, Kingston, Ontario, Canada
| | - James Murray
- AIDS Bureau, Ontario Ministry of Health and Long-Term Care, Toronto, Ontario, Canada
| | - Anita Rachlis
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sean B Rourke
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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19
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Rachlis B, Naanyu V, Wachira J, Genberg B, Koech B, Kamene R, Akinyi J, Braitstein P. Correction to: Identifying common barriers and facilitators to linkage and retention in chronic disease care in western Kenya. BMC Public Health 2018; 18:1003. [PMID: 30097027 PMCID: PMC6086996 DOI: 10.1186/s12889-018-5904-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 11/10/2022] Open
Abstract
After the publication of the original article [1], it was highlighted that Fig. 1 was incorrectly labeled.
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Affiliation(s)
- Beth Rachlis
- Academic Model Providing Access to Healthcare (AMPATH), PO-Box 4606, Eldoret, 30100, Kenya. .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. .,Ontario HIV Treatment Network, Toronto, ON, Canada.
| | - Violet Naanyu
- Academic Model Providing Access to Healthcare (AMPATH), PO-Box 4606, Eldoret, 30100, Kenya.,Department of Behavioral Sciences, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Juddy Wachira
- Academic Model Providing Access to Healthcare (AMPATH), PO-Box 4606, Eldoret, 30100, Kenya
| | - Becky Genberg
- Department of Health Services, Policy and Practice, Program in Public Health, Brown University, Providence, RI, USA
| | - Beatrice Koech
- Academic Model Providing Access to Healthcare (AMPATH), PO-Box 4606, Eldoret, 30100, Kenya
| | - Regina Kamene
- Academic Model Providing Access to Healthcare (AMPATH), PO-Box 4606, Eldoret, 30100, Kenya
| | - Jackie Akinyi
- Academic Model Providing Access to Healthcare (AMPATH), PO-Box 4606, Eldoret, 30100, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), PO-Box 4606, Eldoret, 30100, Kenya.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
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20
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Orkin AM, McArthur A, McDonald A, Mew EJ, Martiniuk A, Buchman DZ, Kouyoumdjian F, Rachlis B, Strike C, Upshur R. Defining and measuring health equity effects in research on task shifting interventions in high-income countries: a systematic review protocol. BMJ Open 2018; 8:e021172. [PMID: 30068611 PMCID: PMC6074666 DOI: 10.1136/bmjopen-2017-021172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Task shifting interventions are intended to both deliver clinically effective treatments to reduce disease burden and address health inequities or population vulnerability. Little is known about how health equity and population vulnerability are defined and measured in research focused on task shifting. This systematic review will address the following questions: Among task shifting interventions in high-income settings that have been studied using randomised controlled trials or variants, how are health inequity or population vulnerability identified and defined? What methods and indicators are used to describe, characterise and measure the population's baseline status and the intervention's impacts on inequity and vulnerability? METHODS AND ANALYSIS Studies were identified through database searches (MEDLINE, Embase, CINAHL, PsycINFO and Web of Science). Eligible studies will be randomised controlled trials published since 2004, conducted in high-income countries, concerning task shifting interventions to treat any disease, in any population that may face health disadvantage as defined by the PROGRESS-Plus framework (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, social capital, socioeconomic position, age, disability, sexual orientation, other vulnerable groups). We will conduct independent and duplicate title and abstract screening, then identify related papers from the same programme of research through further database and manual searching. From each programme of research, we will extract study details, and definitions and measures of health equity or population vulnerability based on the PROGRESS-Plus framework. Two investigators will assess the quality of reporting and measurement related to health equity and vulnerability using a scale developed for this study. A narrative synthesis will highlight similarities and differences between the gathered studies and offer critical analyses and implications. ETHICS AND DISSEMINATION This review does not involve primary data collection, does not constitute research on human subjects and is not subject to additional institutional ethics review or informed consent procedures. Dissemination will include open-access peer-reviewed publication and academic conference presentations.PROSPERO Registration Number CRD42017049959.
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Affiliation(s)
- Aaron M Orkin
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Allison McArthur
- Ontario Public Health Libraries Association, Toronto, Ontario, Canada
| | - André McDonald
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Emma J Mew
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Alexandra Martiniuk
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- George Institute for Global Health Australia, University of Sydney, Sydney, Australia
| | - Daniel Z Buchman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Fiona Kouyoumdjian
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Beth Rachlis
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Ontario HIV Treatment Network, Toronto, Ontario, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ross Upshur
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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21
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Scheim AI, Bardwell G, Rachlis B, Mitra S, Kerr T. Syringe sharing among people who inject drugs in London, Canada. Can J Public Health 2018; 109:174-182. [PMID: 29981046 DOI: 10.17269/s41997-018-0058-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/20/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVES London, Ontario, is facing an outbreak of HIV among people who inject drugs (PWID), as well as persistently high levels of hepatitis C virus (HCV). Syringe sharing is the primary driver of HIV and HCV transmission risks among PWID, however, little is known about factors contributing to syringe sharing in this setting. Therefore, we sought to characterize syringe sharing and its correlates among London PWID. METHODS Between March and April, 2016, PWID participated in a survey administered by peer research associates as part of the Ontario Integrated Supervised Injection Services Feasibility Study. Bivariable and multivariable logistic regression models examined associations with syringe sharing (borrowing or lending previously used syringes) over the previous 6 months. A sub-analysis described patterns of borrowing and lending by self-reported HIV and HCV statuses. RESULTS Of 198 PWID, 44 (22%) reported syringe sharing in the past 6 months. In the multivariable analysis, selling drugs (adjusted odds ratio; AOR = 1.92, 95% CI = 1.20-3.08), daily crystal methamphetamine injection (AOR = 1.66, 95% CI = 1.07-2.59), and identifying as HIV-positive (AOR = 3.11, 95% CI = 1.61-6.01) were independently associated with increased syringe sharing. While not independently associated with syringe sharing, problems accessing syringes were common (13-50%). Self-reported HIV-positive respondents were more likely to report syringe borrowing (p < 0.001), but not lending (p = 0.26). CONCLUSION We observed a high rate of syringe sharing among London PWID, with sharing being associated with high-intensity injection of crystal methamphetamine, as well as with involvement in drug sales. Considering the current HIV outbreak in London, multi-level prevention efforts are urgently needed.
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Affiliation(s)
- Ayden I Scheim
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, N6A 5C1, Canada.,Division of Infectious Diseases and Global Public Health, University of California San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Beth Rachlis
- Ontario HIV Treatment Network, 1300 Yonge Street, Suite 600, Toronto, ON, M4T 1X3, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street West, 6th floor, Toronto, ON, M5T 3M7, Canada
| | - Sanjana Mitra
- British Columbia Centre on Substance Use, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, Canada.,Interdisciplinary Studies, University of British Columbia, 270-2357 Main Mall, Vancouver, British Columbia, V6T 1Z4, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, 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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22
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Palmer A, Gabler K, Rachlis B, Ding E, Chia J, Bacani N, Bayoumi AM, Closson K, Klein M, Cooper C, Burchell A, Walmsley S, Kaida A, Hogg R. Viral suppression and viral rebound among young adults living with HIV in Canada. Medicine (Baltimore) 2018; 97:e10562. [PMID: 29851775 PMCID: PMC6392935 DOI: 10.1097/md.0000000000010562] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Describe the prevalence and covariates of viral suppression and subsequent rebound among younger (≤29 years old) compared with older adults.A retrospective clinical cohort study; eligibility criteria: documented HIV infection; resident of Canada; 18 years and over; first antiretroviral regimen comprised of at least 3 individual agents on or after January 1, 2000.Viral suppression and rebound were defined by at least 2 consecutive viral load measurements <50 or >50 HIV-1 RNA copies/mL, respectively, at least 30 days apart, in a 1-year period. Time to suppression and rebound were measured using the Kaplan-Meier method and Life Table estimates. Accelerated failure time models were used to determine factors independently associated with suppression and rebound.Younger adults experienced lower prevalence of viral suppression and shorter time to viral rebound compared with older adults. For younger adults, viral suppression was associated with being male and later era of combination antiretroviral initiation (cART) initiation. Viral rebound was associated with a history of injection drug use, Indigenous ancestry, baseline CD4 cell count >200, and initiating cART with a protease inhibitor (PI) containing regimen.The influence of age on viral suppression and rebound was modest for this cohort. Our analysis revealed that key covariates of viral suppression and rebound for young adults in Canada are similar to those of known importance to older adults. Women, people who use injection drugs, and people with Indigenous ancestry could be targeted by future health interventions.
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Affiliation(s)
- Alexis Palmer
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC
| | - Karyn Gabler
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC
| | | | - Erin Ding
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC
| | - Jason Chia
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC
| | - Nic Bacani
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC
| | | | - Kalysha Closson
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC
| | - Marina Klein
- Department of Medicine, McGill University Health Centre, Montreal, QB
| | - Curtis Cooper
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa
| | - Ann Burchell
- Dalla Lana School of Public Health, University of Toronto
- St. Michael's Hospital, Toronto, ON
| | - Sharon Walmsley
- Toronto General Research Institute, University Health Network, Toronto, ON
| | - Angela Kaida
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Robert Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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Kennedy MC, Scheim A, Rachlis B, Mitra S, Bardwell G, Rourke S, Kerr T. Willingness to use drug checking within future supervised injection services among people who inject drugs in a mid-sized Canadian city. Drug Alcohol Depend 2018; 185:248-252. [PMID: 29475198 DOI: 10.1016/j.drugalcdep.2017.12.026] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 12/19/2017] [Accepted: 12/20/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Esclating epidemics of fatal overdose are affecting communities across Canada. In many instances, the unanticipated presence of powerful opioids, such as fentanyl, in street drugs is a contributing factor. Drug checking offered within supervised injection services (SIS) is being considered as a potential measure for reducing overdose and related harms. We therefore sought to characterize the willingness of people who inject drugs (PWID) to use drug checking within SIS. METHODS Data were derived from a cross-sectional survey examining the feasibility of SIS in London, Canada, a mid-sized city. Multivariable logistic regression was used to examine factors associated with willingness to frequently (always or usually) use drug checking at SIS. RESULTS Between March and April 2016, 180 PWID were included in the present study, including 68 (38%) women. In total, 78 (43%) reported that they would frequently check their drugs at SIS if this service were available. In multivariable analyses, female gender (Adjusted Odds Ratio [AOR] = 2.31; 95% confidence interval [CI]: (1.20-4.46), homelessness (AOR = 2.36; 95% CI: 1.14-4.86), and drug dealing (AOR = 2.16; 95% CI: 1.07-4.33) were positively associated with willingness to frequently check drugs at SIS. CONCLUSION These findings highlight the potential of drug checking as a complement to other services offered within SIS, particularly given that subpopulations of PWID at heightened risk of overdose were more likely to report willingness to frequently use this service. However, further research is needed to determine the possible health impacts of offering drug checking at SIS.
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Affiliation(s)
- Mary Clare Kennedy
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Ayden Scheim
- Department of Epidemiology and Biostatistics, The University of Western Ontario, Kresge Building Room K201, London, Ontario, N6A 5C1, Canada
| | - Beth Rachlis
- Ontario HIV Treatment Network, 600-1300 Yonge Street, Toronto, Ontario, M4T 1X3, Canada; Division of Clinical Public Health, Dalla Lana School of Public Health, Health Sciences Building, 155 College Street, 6th Floor, University of Toronto, Toronto, Ontario, N6A 5C1, Canada
| | - Sanjana Mitra
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada; Interdisciplinary Studies, University of British Columbia, 270-2357 Main Mall, Vancouver, British Columbia, V6T 1Z4, Canada
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Sean Rourke
- Ontario HIV Treatment Network, 600-1300 Yonge Street, Toronto, Ontario, M4T 1X3, Canada; Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 209 Victoria Street, Toronto, Ontario, M5B 1T8, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada.
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24
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Rachlis B, Karwa R, Chema C, Pastakia S, Olsson S, Wools-Kaloustian K, Jakait B, Maina M, Yotebieng M, Kumarasamy N, Freeman A, de Rekeneire N, Duda SN, Davies MA, Braitstein P. Targeted Spontaneous Reporting: Assessing Opportunities to Conduct Routine Pharmacovigilance for Antiretroviral Treatment on an International Scale. Drug Saf 2017; 39:959-76. [PMID: 27282427 PMCID: PMC5018020 DOI: 10.1007/s40264-016-0434-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Introduction Targeted spontaneous reporting (TSR) is a pharmacovigilance method that can enhance reporting of adverse drug reactions related to antiretroviral therapy (ART). Minimal data exist on the needs or capacity of facilities to conduct TSR. Objectives Using data from the International epidemiologic Databases to Evaluate AIDS (IeDEA) Consortium, the present study had two objectives: (1) to develop a list of facility characteristics that could constitute key assets in the conduct of TSR; (2) to use this list as a starting point to describe the existing capacity of IeDEA-participating facilities to conduct pharmacovigilance through TSR. Methods We generated our facility characteristics list using an iterative approach, through a review of relevant World Health Organization (WHO) and Uppsala Monitoring Centre documents focused on pharmacovigilance activities related to HIV and ART and consultation with expert stakeholders. IeDEA facility data were drawn from a 2009/2010 IeDEA site assessment that included reported characteristics of adult and pediatric HIV care programs, including outreach, staffing, laboratory capacity, adverse event monitoring, and non-HIV care. Results A total of 137 facilities were included: East Africa (43); Asia–Pacific (28); West Africa (21); Southern Africa (19); Central Africa (12); Caribbean, Central, and South America (7); and North America (7). Key facility characteristics were grouped as follows: outcome ascertainment and follow-up; laboratory monitoring; documentation—sources and management of data; and human resources. Facility characteristics ranged by facility and region. The majority of facilities reported that patients were assigned a unique identification number (n = 114; 83.2 %) and most sites recorded adverse drug reactions (n = 101; 73.7 %), while 82 facilities (59.9 %) reported having an electronic database on site. Conclusion We found minimal information is available about facility characteristics that may contribute to pharmacovigilance activities. Our findings, therefore, are a first step that can potentially assist implementers and facility staff to identify opportunities and leverage their existing capacities to incorporate TSR into their routine clinical programs.
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Affiliation(s)
- Beth Rachlis
- Ontario HIV Treatment Network, Toronto, ON, Canada
| | - Rakhi Karwa
- College of Pharmacy, Purdue University, West Lafayette, IN, USA.,Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Celia Chema
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Sonak Pastakia
- College of Pharmacy, Purdue University, West Lafayette, IN, USA.,Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | - Kara Wools-Kaloustian
- Academic Model Providing Access to Healthcare, Eldoret, Kenya.,School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Beatrice Jakait
- Academic Model Providing Access to Healthcare, Eldoret, Kenya.,Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Mercy Maina
- Academic Model Providing Access to Healthcare, Eldoret, Kenya.,Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Marcel Yotebieng
- College of Public Health, Ohio State University, Columbus, OH, USA.,Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Nagalingeswaran Kumarasamy
- YRGCARE Medical Centre, Chennai Antiviral Research and Treatment Clinical Research Site (CART CRS), Voluntary Health Services, Chennai, India
| | - Aimee Freeman
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Stephany N Duda
- Department of Medical Informatics, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare, Eldoret, Kenya. .,Division of Epidemiology, University of Toronto, Dalla Lana School of Public Health, 155 College Street, Toronto, ON, M5T 3M7, Canada. .,Department of Medicine, School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya.
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25
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Mitra S, Rachlis B, Scheim A, Bardwell G, Rourke SB, Kerr T. Acceptability and design preferences of supervised injection services among people who inject drugs in a mid-sized Canadian City. Harm Reduct J 2017; 14:46. [PMID: 28709471 PMCID: PMC5513355 DOI: 10.1186/s12954-017-0174-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/05/2017] [Indexed: 12/01/2022] Open
Abstract
Background Supervised injection services (SIS) have been shown to reduce the public- and individual-level harms associated with injection drug use. While SIS feasibility research has been conducted in large urban centres, little is known about the acceptability of these services among people who inject drugs (PWID) in mid-sized cities. We assessed the prevalence and correlates of willingness to use SIS as well as design and operational preferences among PWID in London, Canada. Methods Between March and April 2016, peer research associates administered a cross-sectional survey to PWID in London. Socio-demographic characteristics, drug-use patterns, and behaviours associated with willingness to use SIS were estimated using bivariable and multivariable logistic regression models. Chi-square tests were used to compare characteristics with expected frequency of SIS use among those willing to use SIS. Design and operational preferences are also described. Results Of 197 PWID included in this analysis (median age, 39; interquartile range (IQR), 33–50; 38% female), 170 (86%) reported willingness to use SIS. In multivariable analyses, being female (adjusted odds ratio (AOR) 0.29; 95% confidence interval (CI) 0.11–0.75) was negatively associated with willingness to use, while public injecting in the last 6 months (AOR 2.76; 95% CI 1.00–7.62) was positively associated with willingness to use. Participants living in unstable housing, those injecting in public, and those injecting opioids and crystal methamphetamine daily reported higher expected frequency of SIS use (p < 0.05). A majority preferred private cubicles for injecting spaces and daytime operational hours, while just under half preferred PWID involved in service operations. Conclusions High levels of willingness to use SIS were found among PWID in this setting, suggesting that these services may play a role in addressing the harms associated with injection drug use. To maximize the uptake of SIS, programme planners and policy makers should consider the effects of gender and views of PWID regarding SIS design and operational preferences.
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Affiliation(s)
- Sanjana Mitra
- The Ontario HIV Treatment Network, 1300 Yonge Street, Suite 600, Toronto, ON, M4T 1X3, Canada
| | - Beth Rachlis
- The Ontario HIV Treatment Network, 1300 Yonge Street, Suite 600, Toronto, ON, M4T 1X3, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON, M5T 3M7, Canada
| | - Ayden Scheim
- Department of Epidemiology and Biostatistics, The University of Western Ontario, K201 Kresge Building, London, ON, N6A 5C1, Canada
| | - Geoff Bardwell
- BC Centre on Substance Use, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Sean B Rourke
- The Ontario HIV Treatment Network, 1300 Yonge Street, Suite 600, Toronto, ON, M4T 1X3, Canada.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - Thomas Kerr
- BC Centre on Substance Use, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, V6Z 1Y6, BC, 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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Rachlis B, Burchell AN, Gardner S, Light L, Raboud J, Antoniou T, Bacon J, Benoit A, Cooper C, Kendall C, Loutfy M, Wobeser W, McGee F, Rachlis A, Rourke SB. Social determinants of health and retention in HIV care in a clinical cohort in Ontario, Canada. AIDS Care 2016; 29:828-837. [PMID: 28027668 DOI: 10.1080/09540121.2016.1271389] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Continuous HIV care supports antiretroviral therapy initiation and adherence, and prolongs survival. We investigated the association of social determinants of health (SDH) and subsequent retention in HIV care in a clinical cohort in Ontario, Canada. The Ontario HIV Treatment Network Cohort Study is a multi-site cohort of patients at 10 HIV clinics. Data were collected from medical charts, interviews, and via record linkage with the provincial public health laboratory for viral load tests. For participants interviewed in 2009, we used three-category multinomial logistic regression to identify predictors of retention in 2010-2012, defined as (1) continuous care (≥2 viral loads ≥90 days in all years; reference category); (2) discontinuous care (only 1 viral load/year in ≥1 year); and (3) a gap in care (≥1 year in 2010-2012 with no viral load). In total, 1838 participants were included. In 2010-2012, 71.7% had continuous care, 20.9% had discontinuous care, and 7.5% had a gap in care. Discontinuous care in 2009 was predictive (p < .0001) of future retention. SDH associated with discontinuous care were Indigenous ethnicity, being born in Canada, being employed, reporting hazardous drinking, and non-injection drug use. Being a heterosexual male was associated with having a gap in care, and being single and younger were associated with discontinuous care and a gap in care. Various SDH were associated with retention. Care discontinuity was highly predictive of future gaps. Targeted strategic interventions that better engage those at risk of suboptimal retention merit exploration. ABBREVIATIONS AOR: adjusted odds ratio; ART: antiretroviral therapy; AUDIT: Alcohol Use Disorders Identification Test; CES-D: Center for Epidemiologic Studies Depression Scale; CIs: confidence intervals; HIV: human immunodeficiency virus; IQR: interquartile range; MSM: men who have sex with men; NA-ACCORD: North American AIDS Cohort Collaboration on Research and Design; OCS: Ontario HIV Treatment Network Cohort Study; OHTN: Ontario HIV Treatment Network; OR: odds ratio; PHOL: Public Health Ontario Laboratories; REB: Research Ethics Board; SDH: social determinants of health; US: United States.
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Affiliation(s)
- Beth Rachlis
- a Ontario HIV Treatment Network , Toronto , Canada.,b Division of Clinical Public Health, Dalla Lana School of Public Health , University of Toronto , Toronto , Canada
| | - Ann N Burchell
- c Division of Epidemiology , Dalla Lana School of Public Health, University of Toronto , Toronto , Canada.,d Department of Family and Community Medicine , St. Michael's Hospital, Toronto , Canada.,e Department of Family and Community Medicine , University of Toronto , Toronto , Canada.,f Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , Canada
| | - Sandra Gardner
- g Division of Biostatistics, Dalla Lana School of Public Health , University of Toronto , Toronto , Canada.,h Rotman Research Institute , Baycrest, Toronto , Canada
| | - Lucia Light
- a Ontario HIV Treatment Network , Toronto , Canada
| | - Janet Raboud
- g Division of Biostatistics, Dalla Lana School of Public Health , University of Toronto , Toronto , Canada.,i Toronto General Research Institute, University Health Network , Toronto , Canada
| | - Tony Antoniou
- d Department of Family and Community Medicine , St. Michael's Hospital, Toronto , Canada.,e Department of Family and Community Medicine , University of Toronto , Toronto , Canada.,f Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , Canada
| | - Jean Bacon
- a Ontario HIV Treatment Network , Toronto , Canada
| | - Anita Benoit
- j Women's College Research Institute, Women's College Hospital , Toronto , Canada
| | - Curtis Cooper
- k Ottawa Hospital Research Institute , Ottawa , Canada
| | - Claire Kendall
- l Bruyère Research Institute , Ottawa , Canada.,m Department of Family Medicine , University of Ottawa , Ottawa , Canada
| | - Mona Loutfy
- n Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health , Toronto , Canada.,o Department of Medicine , Women's College Research Institute, Women's College Hospital , Toronto , Canada.,p Department of Medicine , University of Toronto , Toronto , Canada
| | - Wendy Wobeser
- q Department of Medicine , Queen's University , Kingston , Canada.,r Hotel Dieu Hospital , Kingston , Canada
| | - Frank McGee
- s AIDS Bureau, Ontario Ministry of Health and Long Term Care , Toronto , Canada
| | - Anita Rachlis
- p Department of Medicine , University of Toronto , Toronto , Canada.,t Sunnybrook Health Science Centre , Toronto , Canada
| | - Sean B Rourke
- a Ontario HIV Treatment Network , Toronto , Canada.,f Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , Canada.,u Department of Psychiatry , University of Toronto , Toronto , Canada
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- a Ontario HIV Treatment Network , Toronto , Canada
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27
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Genberg BL, Shangani S, Sabatino K, Rachlis B, Wachira J, Braitstein P, Operario D. Improving Engagement in the HIV Care Cascade: A Systematic Review of Interventions Involving People Living with HIV/AIDS as Peers. AIDS Behav 2016; 20:2452-2463. [PMID: 26837630 DOI: 10.1007/s10461-016-1307-z] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Improving patient engagement in HIV care is critical for maximizing the impact of antiretroviral therapy (ART). We conducted a systematic review of studies that used HIV-positive peers to bolster linkage, retention, and/or adherence to ART. We searched articles published and indexed in Pubmed, PsycINFO, and CINAHL between 1996 and 2014. Peers were required to be HIV-positive. Studies were restricted to those published in English. Nine studies with n = 4658 participants met the inclusion criteria. Peer-based interventions were predominantly focused on improving adherence to ART, or evaluations of retention and adherence via viral suppression. Five (56 %) were conducted in sub-Saharan Africa. Overall findings were mixed on the impact of peers on ART adherence, viral suppression, and mortality. While positive effects of peer interventions on improving linkage and retention were found, there were limited studies assessing these outcomes. Additional research is warranted to demonstrate the impact of peers on linkage and retention in diverse populations.
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Rachlis B, Bakoyannis G, Easterbrook P, Genberg B, Braithwaite RS, Cohen CR, Bukusi EA, Kambugu A, Bwana MB, Somi GR, Geng EH, Musick B, Yiannoutsos CT, Wools-Kaloustian K, Braitstein P. Facility-Level Factors Influencing Retention of Patients in HIV Care in East Africa. PLoS One 2016; 11:e0159994. [PMID: 27509182 PMCID: PMC4980048 DOI: 10.1371/journal.pone.0159994] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/12/2016] [Indexed: 12/25/2022] Open
Abstract
Losses to follow-up (LTFU) remain an important programmatic challenge. While numerous patient-level factors have been associated with LTFU, less is known about facility-level factors. Data from the East African International epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium was used to identify facility-level factors associated with LTFU in Kenya, Tanzania and Uganda. Patients were defined as LTFU if they had no visit within 12 months of the study endpoint for pre-ART patients or 6 months for patients on ART. Adjusting for patient factors, shared frailty proportional hazard models were used to identify the facility-level factors associated with LTFU for the pre- and post-ART periods. Data from 77,362 patients and 29 facilities were analyzed. Median age at enrolment was 36.0 years (Interquartile Range: 30.1, 43.1), 63.9% were women and 58.3% initiated ART. Rates (95% Confidence Interval) of LTFU were 25.1 (24.7–25.6) and 16.7 (16.3–17.2) per 100 person-years in the pre-ART and post-ART periods, respectively. Facility-level factors associated with increased LTFU included secondary-level care, HIV RNA PCR turnaround time >14 days, and no onsite availability of CD4 testing. Increased LTFU was also observed when no nutritional supplements were provided (pre-ART only), when TB patients were treated within the HIV program (pre-ART only), and when the facility was open ≤4 mornings per week (ART only). Our findings suggest that facility-based strategies such as point of care laboratory testing and separate clinic spaces for TB patients may improve retention.
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Affiliation(s)
- Beth Rachlis
- The Ontario HIV Treatment Network, Toronto, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Giorgos Bakoyannis
- Department of Biostatistics, Richard Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America
| | | | - Becky Genberg
- Department of Health Services, Brown University, Providence, Rhode Island, United States of America
| | - Ronald Scott Braithwaite
- Department of Population Health, School of Medicine, New York University, New York, New York, United States of America
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Mwebesa Bosco Bwana
- Department of Internal Medicine, Mbarara University of Science & Technology, Mbarara, Uganda
| | | | - Elvin H Geng
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Beverly Musick
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Constantin T Yiannoutsos
- Department of Biostatistics, Richard Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America
| | - Kara Wools-Kaloustian
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Paula Braitstein
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.,Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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29
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Rachlis B, Cole DC, van Lettow M, Escobar M. Survival functions for defining a clinical management Lost To Follow-Up (LTFU) cut-off in Antiretroviral Therapy (ART) program in Zomba, Malawi. BMC Med Inform Decis Mak 2016; 16:52. [PMID: 27150958 PMCID: PMC4857410 DOI: 10.1186/s12911-016-0290-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 04/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While, lost to follow-up (LTFU) from antiretroviral therapy (ART) can be considered a catch-all category for patients who miss scheduled visits or medication pick-ups, operational definitions and methods for defining LTFU vary making comparisons across programs challenging. Using weekly cut-offs, we sought to determine the probability that an individual would return to clinic given that they had not yet returned in order to identify the LTFU cut-off that could be used to inform clinical management and tracing procedures. METHODS Individuals who initiated ART with Dignitas International supported sites (n = 22) in Zomba, Malawi between January 1 2007-June 30 2010 and were ≥ 1 week late for a follow-up visit were included. Lateness was categorized using weekly cut-offs from ≥1 to ≥26 weeks late. At each weekly cut-off, the proportion of patients who returned for a subsequent follow-up visit were identified. Cumulative Distribution Functions (CDFs) were plotted to determine the probability of returning as a function of lateness. Hazard functions were plotted to demonstrate the proportion of patients who returned each weekly interval relative to those who had yet to return. RESULTS In total, n = 4484 patients with n = 7316 follow-up visits were included. The number of included follow-up visits per patient ranged from 1-10 (median: 1). Both the CDF and hazard function demonstrated that after being ≥9 weeks late, the proportion of new patients who returned relative to those who had yet to return decreased substantially. CONCLUSIONS We identified a LTFU definition useful for clinical management. The simple functions plotted here did not require advanced statistical expertise and were created using Microsoft Excel, making it a particularly practical method for HIV programs in resource-constrained settings.
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Affiliation(s)
- Beth Rachlis
- The Ontario HIV Treatment Network, Toronto, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Donald C Cole
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Monique van Lettow
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. .,Dignitas International, Zomba, Malawi.
| | - Michael Escobar
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Rachlis B, Naanyu V, Wachira J, Genberg B, Koech B, Kamene R, Akinyi J, Braitstein P. Community Perceptions of Community Health Workers (CHWs) and Their Roles in Management for HIV, Tuberculosis and Hypertension in Western Kenya. PLoS One 2016; 11:e0149412. [PMID: 26901854 PMCID: PMC4764025 DOI: 10.1371/journal.pone.0149412] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 02/01/2016] [Indexed: 11/19/2022] Open
Abstract
Given shortages of health care providers and a rise in the number of people living with both communicable and non-communicable diseases, Community Health Workers (CHWs) are increasingly incorporated into health care programs. We sought to explore community perceptions of CHWs including perceptions of their roles in chronic disease management as part of the Academic Model Providing Access to Healthcare Program (AMPATH) in western Kenya. In depth interviews and focus group discussions were conducted between July 2012 and August 2013. Study participants were purposively sampled from three AMPATH sites: Chulaimbo, Teso and Turbo, and included patients within the AMPATH program receiving HIV, tuberculosis (TB), and hypertension (HTN) care, as well as caregivers of children with HIV, community leaders, and health care workers. Participants were asked to describe their perceptions of AMPATH CHWs, including identifying the various roles they play in engagement in care for chronic diseases including HIV, TB and HTN. Data was coded and various themes were identified. We organized the concepts and themes generated using the Andersen-Newman Framework of Health Services Utilization and considering CHWs as a potential enabling resource. A total of 207 participants including 110 individuals living with HIV (n = 50), TB (n = 39), or HTN (n = 21); 24 caregivers; 10 community leaders; and 34 healthcare providers participated. Participants identified several roles for CHWs including promoting primary care, encouraging testing, providing education and facilitating engagement in care. While various facilitating aspects of CHWs were uncovered, several barriers of CHW care were raised, including issues with training and confidentiality. Suggested resources to help CHWs improve their services were also described. Our findings suggest that CHWs can act as catalysts and role models by empowering members of their communities with increased knowledge and support.
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Affiliation(s)
- Beth Rachlis
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- University of Toronto, Dalla Lana School of Public Health, Toronto, Ontario, Canada
- The Ontario HIV Treatment Network, Toronto, Ontario, Canada
| | - Violet Naanyu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Juddy Wachira
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Becky Genberg
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island, United States
| | - Beatrice Koech
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Regina Kamene
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jackie Akinyi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- University of Toronto, Dalla Lana School of Public Health, Toronto, Ontario, Canada
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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Rachlis B, Ochieng D, Geng E, Rotich E, Ochieng V, Maritim B, Ndege S, Naanyu V, Martin JN, Keter A, Ayuo P, Diero L, Nyambura M, Braitstein P. Implementation and operational research: evaluating outcomes of patients lost to follow-up in a large comprehensive care treatment program in western Kenya. J Acquir Immune Defic Syndr 2015; 68:e46-55. [PMID: 25692336 PMCID: PMC4348019 DOI: 10.1097/qai.0000000000000492] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Academic Model Providing Access To Healthcare (AMPATH) program provides comprehensive HIV care and treatment services. Approximately, 30% of patients have become lost to follow-up (LTFU). We sought to actively trace and identify outcomes for a sample of these patients. METHODS LTFU was defined as missing a scheduled visit by ≥3 months. A randomly selected sample of 17% of patients identified as LTFU between January 2009 and June 2011 was generated, with sample stratification on age, antiretroviral therapy (ART) status at last visit, and facility. Chart reviews were conducted followed by active tracing. Tracing was completed by trained HIV-positive outreach workers July 2011 to February 2012. Outcomes were compared between adults and children and by ART status. RESULTS Of 14,811 LTFU patients, 2540 were randomly selected for tracing (2179 adults, 1071 on ART). The chart reviews indicated that 326 (12.8%) patients were not actually LTFU. Outcomes for 71% of sampled patients were determined including 85% of those physically traced. Of those with known outcomes, 21% had died, whereas 29% had disengaged from care for various reasons. The remaining patients had moved away (n = 458, 25%) or were still receiving HIV care (n = 443 total, 25%). CONCLUSIONS Our findings demonstrate the feasibility of a large-scale sampling-based approach. A significant proportion of patients were found not to be LTFU, and further, high numbers of patients who were LTFU could not be located. Over a quarter of patients disengaged from care for various reasons including access challenges and familial influences.
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Affiliation(s)
- Beth Rachlis
- *Academic Model Providing Access To Healthcare, Eldoret, Kenya; †Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; ‡Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA; §Moi University School of Public Health, Kenya; Departments of ‖Behavioral Sciences; and ¶Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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Mills E, Cooper C, Wu P, Rachlis B, Singh S, Guyatt GH. Randomized Trials Stopped Early for Harm in HIV/AIDS: A Systematic Survey. HIV Clinical Trials 2015; 7:24-33. [PMID: 16684642 DOI: 10.1310/feed-6t8u-0bug-6hqh] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The decision to stop trials early because of the harmful effects of the intervention is complex and requires weighing statistical, logistical, and ethical considerations. We assessed the prevalence of randomized clinical trials (RCTs) stopped early for harm in HIV/AIDS and determined the quality of reporting of methods to inform the decision to stop the trial. METHOD We searched 11 electronic databases and major conference abstract databases, contacted trialist and advocacy groups, and searched the Internet. We selected RCTs stopped early for harm. We extracted data on journal and year of publication, reporting of methods and funding, planned sample size, number and planning of interim analyses, stopping rules, and effect size of the harm outcomes. RESULTS We found 10 RCTs stopped early for harm (median, n = 85; range, 7-1227). Most interventions (n = 9) were antiviral drugs; one trial studied vitamins to prevent vertical transmission of HIV. Five studies reported a priori defined adverse events, and only 1 trial reported planned stopping guidelines. The primary harm outcomes reported across trials included toxicity, death, and increased mother-to-child transmission. Two trials were stopped due to sudden unanticipated adverse events (Stevens-Johnson syndrome, death, and encephalopathy). Relative risk point estimates for harm ranged from 1 to 6.18. Six studies reported the presence of a data safety and monitoring board. CONCLUSION The reporting of methods to inform the decision to stop trials for harm in this population is deficient in a variety of ways, including lack of stopping guidelines. Clinicians should interpret RCTs stopped early for harm with caution and interpret the results in light of related evidence. Trialists should improve the transparency of their decision-making regarding early stopping for harmful effects.
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Affiliation(s)
- Edward Mills
- Centre for International Health and Human Rights Studies, North York, Ontario, Canada.
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Rachlis B, Ahmad F, van Lettow M, Muula AS, Semba M, Cole DC. Using concept mapping to explore why patients become lost to follow up from an antiretroviral therapy program in the Zomba District of Malawi. BMC Health Serv Res 2013; 13:210. [PMID: 23758879 PMCID: PMC3698212 DOI: 10.1186/1472-6963-13-210] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 06/01/2013] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Retention in antiretroviral therapy (ART) programmes remains a challenge in many settings including Malawi, in part due to high numbers of losses to follow-up. Concept Mapping (CM), a mix-method participatory approach, was used to explore why patients on ART are lost to follow-up (LTFU) by identifying: 1) factors that influence patient losses to follow-up and 2) barriers to effective and efficient tracing in Zomba, Malawi. METHODS CM sessions (brainstorming, sorting and rating, interpretation) were conducted in urban and rural settings in Zomba, Malawi. Participants included ART patients, ART providers, Health Surveillance Assistants, and health managers from the Zomba District Health Office. In brainstorming, participants generated statements in response to "A specific reason why an individual on ART becomes lost to follow-up is…" Participants then sorted and rated the consolidated list of brainstormed items. Analysis included inductive qualitative methods for grouping of data and quantitative cluster identification to produce visual maps which were then interpreted by participants. RESULTS In total, 90 individuals brainstormed 371 statements, 64 consolidated statements were sorted (participant n = 46), and rated on importance and feasibility (participant n = 69). A nine-cluster concept map was generated and included both patient- and healthcare-related clusters such as: Stigma and Fears, Beliefs, Acceptance and Knowledge of ART, Access to ART, Poor Documentation, Social and Financial Support Issues, Health Worker Attitudes, Resources Needed for Effective Tracing, and Health Worker Issues Related to Tracing. Strategies to respond to the clusters were generated in Interpretation. CONCLUSIONS Multiple patient- and healthcare focused factors influence why patients become LTFU. Findings have implications particularly for programs with limited resources struggling with the retention of ART patients.
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Affiliation(s)
- Beth Rachlis
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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Rachlis B, Sodhi S, Burciul B, Orbinski J, Cheng AHY, Cole D. A taxonomy for community-based care programs focused on HIV/AIDS prevention, treatment, and care in resource-poor settings. Glob Health Action 2013; 6:1-21. [PMID: 23594416 PMCID: PMC3629264 DOI: 10.3402/gha.v6i0.20548] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 03/18/2013] [Accepted: 03/18/2013] [Indexed: 11/25/2022] Open
Abstract
Community-based care (CBC) can increase access to key services for people affected by HIV/AIDS through the mobilization of community interests and resources and their integration with formal health structures. Yet, the lack of a systematic framework for analysis of CBC focused on HIV/AIDS impedes our ability to understand and study CBC programs. We sought to develop taxonomy of CBC programs focused on HIV/AIDS in resource-limited settings in an effort to understand their key characteristics, uncover any gaps in programming, and highlight the potential roles they play. Our review aimed to systematically identify key CBC programs focused on HIV/AIDS in resource-limited settings. We used both bibliographic database searches (Medline, CINAHL, and EMBASE) for peer-reviewed literature and internet-based searches for gray literature. Our search terms were ‘HIV’ or ‘AIDS’ and ‘community-based care’ or ‘CBC’. Two co-authors developed a descriptive taxonomy through an iterative, inductive process using the retrieved program information. We identified 21 CBC programs useful for developing taxonomy. Extensive variation was observed within each of the nine categories identified: region, vision, characteristics of target populations, program scope, program operations, funding models, human resources, sustainability, and monitoring and evaluation strategies. While additional research may still be needed to identify the conditions that lead to overall program success, our findings can help to inform our understanding of the various aspects of CBC programs and inform potential logic models for CBC programming in the context of HIV/AIDS in resource-limited settings. Importantly, the findings of the present study can be used to develop sustainable HIV/AIDS-service delivery programs in regions with health resource shortages.
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Affiliation(s)
- Beth Rachlis
- Global Health Division Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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Pinto AD, van Lettow M, Rachlis B, Chan AK, Sodhi SK. Patient costs associated with accessing HIV/AIDS care in Malawi. J Int AIDS Soc 2013; 16:18055. [PMID: 23517716 PMCID: PMC3604364 DOI: 10.7448/ias.16.1.18055] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 01/18/2013] [Accepted: 01/29/2013] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION The decentralization of HIV services has been shown to improve equity in access to care for the rural poor of sub-Saharan Africa. This study aims to contribute to our understanding of the impact of decentralization on costs borne by patients. Such information is valuable for economic evaluations of anti-retroviral therapy programmes that take a societal perspective. We compared costs reported by patients who received care in an urban centralized programme to those in the same district who received care through rural decentralized care (DC). METHODS A cross-sectional survey on patient characteristics and costs associated with accessing HIV care was conducted, in May 2010, on 120 patients in centralized care (CC) at a tertiary referral hospital and 120 patients in DC at five rural health centres in Zomba District, Malawi. Differences in costs borne by each group were compared using χ2 and t-tests, and a regression model was developed to adjust for confounders, using bootstrapping to address skewed cost data. RESULTS There was no significant difference between the groups with respect to sex and age. However, there were significant differences in socio-economic status, with higher educational attainment (p<0.001), personal income (p=0.007) and household income per person (p=0.005) in CC. Travel times were similar (p=0.65), as was time waiting at the clinic (p=0.63) and total time spent seeking care (p=0.65). There was a significant difference in travel-related expenses (p<0.001) related to the type of travel participants noted that they used. In CC, 60% of participants reported using a mini-bus to reach the clinic; in DC only 4% reported using a mini-bus, and the remainder reported travelling on foot or by bicycle. There were no significant differences between the groups in the amount of lost income reported or other out-of-pocket costs. Approximately 91 Malawi Kwacha (95% confidence intervals: 1-182 MKW) or US$0.59 represents the adjusted difference in total costs per visit between CC and DC. CONCLUSIONS Even within a system of HIV/AIDS care where patients do not pay to see clinicians or for most medications, they still incur costs. We found that most costs are travel related. This has important implications for poorer patients who live at a distance from health facilities for whom these costs may be significant.
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Affiliation(s)
- Andrew D Pinto
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada.
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Rachlis B, Lloyd-Smith E, Small W, Tobin D, Stone D, Li K, Wood E, Kerr T. Harmful microinjecting practices among a cohort of injection drug users in vancouver Canada. Subst Use Misuse 2010; 45:1351-66. [PMID: 20509739 PMCID: PMC3782079 DOI: 10.3109/10826081003767643] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES We sought to identify factors associated with harmful microinjecting practices in a longitudinal cohort of IDU. METHODS Using data from the Vancouver Injection Drug Users Study (VIDUS) between January 2004 and December 2005, generalized estimating equations (GEE) logistic regression was performed to examine sociodemographic and behavioral factors associated with four harmful microinjecting practices (frequent rushed injecting, frequent syringe borrowing, frequently injecting with a used water capsule, frequently injecting alone). RESULTS In total, 620 participants were included in the present analysis. Our study included 251 (40.5%) women and 203 (32.7%) self-identified Aboriginal participants. The median age was 31.9 (interquartile range: 23.4-39.3). GEE analyses found that each harmful microinjecting practice was associated with a unique profile of sociodemographic and behavioral factors. DISCUSSION We observed high rates of harmful microinjecting practices among IDU. The present study describes the epidemiology of harmful microinjecting practices and points to the need for strategies that target higher risk individuals including the use of peer-driven programs and drug-specific approaches in an effort to promote safer injecting practices.
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Affiliation(s)
- Beth Rachlis
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
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Mills E, Wilson K, Foster B, Phillips E, Walker S, Rachlis B, Montori VM, Myers SP, Clarke M, Gallicano S. Silybum marianum (milk thistle) and indinavir: an RCT and meta-analysis. ACTA ACUST UNITED AC 2010. [DOI: 10.1111/j.2042-7166.2004.tb04536.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Eyawo O, Nachega J, Lefebvre P, Meyer D, Rachlis B, Lee CW, Kelly S, Mills E. Efficacy and safety of prostaglandin analogues in patients with predominantly primary open-angle glaucoma or ocular hypertension: a meta-analysis. Clin Ophthalmol 2009; 3:447-56. [PMID: 19684868 PMCID: PMC2724035 DOI: 10.2147/opth.s6501] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background First-line therapy for primary open-angle glaucoma and ocular hypertension generally involves prostaglandin analogue therapy. The relative efficacy of differing prostaglandin therapy is disputed. Methods A meta-analysis was conducted of head-to-head randomized trials of prostaglandin therapies. We included randomized trials assessing head-to-head evaluations of prostaglandin analogues travoprost, latanoprost and bimatoprost in patients with predominantly primary open-angle glaucoma or ocular hypertension. Findings were interpreted in light of equivalence margins. Results Our search identified 16 eligible trials, of which 15 were included in the meta-analysis. Trials were, in general, poorly reported. We pooled 9 trials assessing IOP-lowering effects of travoprost vs latanoprost (total n = 1098, weighted mean difference [WMD], −0.24 mmHg, 95% CI, −0.87 to 0.38, P = 0.45, I2 = 56%, 95% CI, 0 to 0.77, heterogeneity P = 0.01). Eight trials assessed travoprost vs bimatoprost (total n = 714, WMD, 0.88 mmHg, 95% CI, 0.13 to 1.63, P = 0.02, I2 = 56%, 95% CI, 0% to 78%, heterogeneity P = 0.02). And 8 trials assessed latanoprost vs bimatoprost (total n = 943, WMD, 0.73 mmHg, 95% CI, 0.10 to 1.37, P = 0.02, I2 = 47%, 95% CI, 0% to 74%, heterogeneity P = 0.06). Travoprost was associated with greater incidence of conjunctival hyperemia than latanoprost (RR 5.71, 95% CI, 1.81 to 18.02, P ≤ 0.001, I2 = 97%, 95% CI, 95 to 98, P ≤ 0.001). Five trials assessing latanoprost and bimatoprost revealed an elevated risk of conjunctival hyperemia with bimatoprost (RR 1.59, 95% CI, 1.02 to 2.48, P = 0.04, I2 = 76%, 95% CI, 16 to 88, P = 0.002). Conclusion Randomized head-to-head evaluations of prostaglandin therapy demonstrate similar efficacy effects, but differing hyperemia effects.
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Affiliation(s)
- Oghenowede Eyawo
- Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
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Mills EJ, Rachlis B, O'Regan C, Thabane L, Perri D. Metastatic renal cell cancer treatments: an indirect comparison meta-analysis. BMC Cancer 2009; 9:34. [PMID: 19173737 PMCID: PMC2637892 DOI: 10.1186/1471-2407-9-34] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Accepted: 01/27/2009] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Treatment for metastatic renal cell cancer (mRCC) has advanced dramatically with understanding of the pathogenesis of the disease. New treatment options may provide improved progression-free survival (PFS). We aimed to determine the relative effectiveness of new therapies in this field. METHODS We conducted comprehensive searches of 11 electronic databases from inception to April 2008. We included randomized trials (RCTs) that evaluated bevacizumab, sorafenib, and sunitinib. Two reviewers independently extracted data, in duplicate. Our primary outcome was investigator-assessed PFS. We performed random-effects meta-analysis with a mixed treatment comparison analysis. RESULTS We included 3 bevacizumab (2 of bevacizumab plus interferon-a [IFN-a]), 2 sorafenib, 1 sunitinib, and 1 temsirolimus trials (total n = 3,957). All interventions offer advantages for PFS. Using indirect comparisons with interferon-alpha as the common comparator, we found that sunitinib was superior to both sorafenib (HR 0.58, 95% CI, 0.38-0.86, P = < 0.001) and bevacizumab + IFN-a (HR 0.75, 95% CI, 0.60-0.93, P = 0.001). Sorafenib was not statistically different from bevacizumab +IFN-a in this same indirect comparison analysis (HR 0.77, 95% CI, 0.52-1.13, P = 0.23). Using placebo as the similar comparator, we were unable to display a significant difference between sorafenib and bevacizumab alone (HR 0.81, 95% CI, 0.58-1.12, P = 0.23). Temsirolimus provided significant PFS in patients with poor prognosis (HR 0.69, 95% CI, 0.57-0.85). CONCLUSION New interventions for mRCC offer a favourable PFS for mRCC compared to interferon-alpha and placebo.
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Affiliation(s)
- Edward J Mills
- Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Beth Rachlis
- Department of Public Health Sciences, University of Toronto, Toronto, Canada
| | - Chris O'Regan
- Department of Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Lehana Thabane
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
- Centre for Evaluation of Medicines, St. Joseph's Healthcare, Hamilton, Canada
| | - Dan Perri
- Centre for Evaluation of Medicines, St. Joseph's Healthcare, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
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Mills EJ, Rachlis B, Wu P, Devereaux PJ, Arora P, Perri D. Primary prevention of cardiovascular mortality and events with statin treatments: a network meta-analysis involving more than 65,000 patients. J Am Coll Cardiol 2008; 52:1769-81. [PMID: 19022156 DOI: 10.1016/j.jacc.2008.08.039] [Citation(s) in RCA: 387] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 08/20/2008] [Accepted: 08/25/2008] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This study aimed to evaluate the effectiveness of 3-hydroxy-3-methyl-glutaryl-CoA reductase inhibitors (statins) in primary prevention of cardiovascular events. BACKGROUND The role of statins is well established for secondary prevention of cardiovascular disease (CVD) clinical events and mortality. Little is known of their role in primary cardiovascular event prevention. METHODS We conducted comprehensive searches of 10 electronic databases from inception to May 2008. We contacted study investigators and maintained a comprehensive bibliography of statin studies. We included randomized trials of at least 12-month duration in predominantly primary prevention populations. Two reviewers independently extracted data in duplicate. We performed random-effects meta-analysis and meta-regression, calculated optimal information size, and conducted a mixed-treatment comparison analysis. RESULTS We included 20 randomized clinical trials. We pooled 19 trials (n = 63,899) for all-cause mortality and found a relative risk (RR) of 0.93 (95% confidence interval [CI]: 0.87 to 0.99, p = 0.03 [I(2) = 5%, 95% CI: 0% to 51%]). Eighteen trials (n = 59,469) assessed cardiovascular deaths (RR: 0.89, 95% CI: 0.81 to 0.98, p = 0.01 [I(2) = 0%, 95% CI: 0% to 41%]). Seventeen trials (n = 53,371) found an RR of 0.85 (95% CI: 0.77 to 0.95, p = 0.004 [I(2) = 61%, 95% CI: 38% to 77%]) for major cardiovascular events, and 17 trials (n = 52,976) assessed myocardial infarctions (RR: 0.77, 95% CI: 0.63 to 0.95, p = 0.01 [I(2) = 59%, 95% CI: 24% to 74%]). Incidence of cancer was not elevated in 10 trials (n = 45,469) (RR: 1.02, 95% CI: 0.94 to 1.11, p = 0.59 [I(2) = 0%, 95% CI: 0% to 46%]), nor was rhabdomyolysis (RR: 0.97, 95% CI: 0.25 to 3.83, p = 0.96 [I(2) = 0%, 95% CI: 0% to 40%]). Our analysis included a sufficient sample to reliably answer our primary outcome of CVD mortality. CONCLUSIONS Statins have a clear role in primary prevention of CVD mortality and major events.
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Affiliation(s)
- Edward J Mills
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
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Eyawo O, Lee CW, Rachlis B, Mills EJ. Reporting of noninferiority and equivalence randomized trials for major prostaglandins: a systematic survey of the ophthalmology literature. Trials 2008; 9:69. [PMID: 19055743 PMCID: PMC2621118 DOI: 10.1186/1745-6215-9-69] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2008] [Accepted: 12/03/2008] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Standards for reporting clinical trials have improved the transparency of patient-important research. The Consolidated Standards of Reporting Trials (CONSORT) published an extension to address noninferiority and equivalence trials. We aimed to determine the reporting quality of prostaglandin noninferiority and equivalence trials in the treatment of glaucoma. METHODS We searched, independently and in duplicate, 6 electronic databases for eligible trials evaluating prostaglandins. We abstracted data on reporting of methodological criteria, including reporting of per-protocol [PP] and intention-to-treat [ITT] analysis, sample size estimation with margins, type of statistical analysis conducted, efficacy summaries, and use of hyperemia measures. RESULTS Trials involving the four major prostaglandin groups (latanoprost, travoprost, bimatoprost, unoprostone) were analyzed. We included 36 noninferiority and 11 equivalence trials. Seventeen out of the included 47 trials (36%, 95% Confidence Intervals [CI]: 24-51) were crossover designs. Only 3 studies (6%, 95% CI: 2-17) reported a presented results of both ITT and PP populations. Twelve studies (26%, 95% CI: 15-39) presented only ITT results but mentioned that PP population had similar results. Thirteen trials (28%, 95% CI: 17-42) presented only PP results with no mention of ITT population results while 17 studies (36%, 95% CI: 24-51) presented only ITT results with no mention of PP population results. Thirty-four (72%, 95% CI: 58-83) of studies adequately described their margin of noninferiority/equivalence. Sequence generation was reported in 22/47 trials (47%, 95% CI: 33-61). Allocation concealment was reported in only 10/47 (21%, 95% CI: 12-35) of the trials. Thirty-five studies (74%, 95% CI: 60-85) employed masking of at least two groups, 4/47 (9%, 95% CI: 3-20) masked only patients and 8/47 (17%, 95% CI: 9-30) were open label studies. Eight (17%, 95% CI: 9-30) of the 47 trials employed a combined test of noninferiority and superiority. We also found 6 differing methods of evaluating hyperemia. CONCLUSION The quality of reporting noninferiority/equivalency trials in the field of glaucoma is markedly heterogeneous. The adoption of the extended CONSORT statement by journals will potentially improve the transparency of this field.
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Affiliation(s)
- Oghenowede Eyawo
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Chia-Wen Lee
- Department of Outcomes Research and Evidence Based Medicine, Pfizer Ltd., Surrey, UK
| | - Beth Rachlis
- Department of Public Health, University of Toronto, Toronto, Canada
| | - Edward J Mills
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
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Abstract
The HIV/AIDS pandemic is considered a security threat. Policy-makers have warned of destabilization of militaries due to massive troop deaths. Estimates of the rate of HIV within African militaries have been as high as 90 per cent. We aimed to determine if HIV prevalence within African militaries is higher than their host nation prevalence rates. Using systematic searching and access to United States Department of Defense data, we abstracted data on prevalence within militaries and their host communities. We conducted a random effects pooled analysis to determine differences in HIV prevalence rates in the military versus the host population. We obtained data on 21 African militaries. In general, HIV prevalence within the military is elevated compared to the general population. The differences were significant (odds ratio 1.97, 95% confidence interval: 1.58-2.45, P < 0.001). Further, inflated rates of HIV in militaries compared to non-military males of similar age were also significant (6.09, 4.47-8.30, P < or = 0.0001). States with recent conflicts and wars had elevated military rates, but these were also not significant (P = 0.4). Population levels predicted military prevalence rates (P < or = 0.001). HIV/AIDS prevalence rates in most African militaries are significantly elevated compared to their host communities.
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Affiliation(s)
- Oumar Ba
- Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
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Rachlis B, Brouwer KC, Mills EJ, Hayes M, Kerr T, Hogg RS. Migration and transmission of blood-borne infections among injection drug users: understanding the epidemiologic bridge. Drug Alcohol Depend 2007; 90:107-19. [PMID: 17485179 DOI: 10.1016/j.drugalcdep.2007.03.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Revised: 03/29/2007] [Accepted: 03/29/2007] [Indexed: 12/01/2022]
Abstract
Migration is one of many social factors contributing to the spread of HIV and other blood-borne or sexually transmitted infections (STI). Bringing together large numbers of people from diverse settings, the process of migration moves infected individuals to diverse geographic locations. Injection drug users (IDU) are a relatively mobile group, often moving between cities, smaller communities, and across international borders for reasons of work, security, or access to narcotics. This mobility indicates the potential for IDU who engage in risky behavior outside their home areas to transmit HIV infection to other IDU, their sex partners, and others in the population. The objectives of this review are to examine: (1) the influence of drug trafficking and the spread of drug use on the diffusion of HIV, (2) the influence of migration on drug use and HIV-related risk behaviors among migrants, and (3) the mobility patterns of IDU and its role in the spread of HIV. We also discuss the potential policy implications of addressing prevention and care issues in mobile drug using populations.
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Affiliation(s)
- Beth Rachlis
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, British Columbia, Canada.
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Mills EJ, Nachega JB, Bangsberg DR, Singh S, Rachlis B, Wu P, Wilson K, Buchan I, Gill CJ, Cooper C. Adherence to HAART: a systematic review of developed and developing nation patient-reported barriers and facilitators. PLoS Med 2006; 3:e438. [PMID: 17121449 PMCID: PMC1637123 DOI: 10.1371/journal.pmed.0030438] [Citation(s) in RCA: 546] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2005] [Accepted: 09/04/2006] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adherence to highly active antiretroviral therapy (HAART) medication is the greatest patient-enabled predictor of treatment success and mortality for those who have access to drugs. We systematically reviewed the literature to determine patient-reported barriers and facilitators to adhering to antiretroviral therapy. METHODS AND FINDINGS We examined both developed and developing nations. We searched the following databases: AMED (inception to June 2005), Campbell Collaboration (inception to June 2005), CinAhl (inception to June 2005), Cochrane Library (inception to June 2005), Embase (inception to June 2005), ERIC (inception to June 2005), MedLine (inception to June 2005), and NHS EED (inception to June 2005). We retrieved studies conducted in both developed and developing nation settings that examined barriers and facilitators addressing adherence. Both qualitative and quantitative studies were included. We independently, in duplicate, extracted data reported in qualitative studies addressing adherence. We then examined all quantitative studies addressing barriers and facilitators noted from the qualitative studies. In order to place the findings of the qualitative studies in a generalizable context, we meta-analyzed the surveys to determine a best estimate of the overall prevalence of issues. We included 37 qualitative studies and 47 studies using a quantitative methodology (surveys). Seventy-two studies (35 qualitative) were conducted in developed nations, while the remaining 12 (two qualitative) were conducted in developing nations. Important barriers reported in both economic settings included fear of disclosure, concomitant substance abuse, forgetfulness, suspicions of treatment, regimens that are too complicated, number of pills required, decreased quality of life, work and family responsibilities, falling asleep, and access to medication. Important facilitators reported by patients in developed nation settings included having a sense of self-worth, seeing positive effects of antiretrovirals, accepting their seropositivity, understanding the need for strict adherence, making use of reminder tools, and having a simple regimen. Among 37 separate meta-analyses examining the generalizability of these findings, we found large heterogeneity. CONCLUSIONS We found that important barriers to adherence are consistent across multiple settings and countries. Research is urgently needed to determine patient-important factors for adherence in developing world settings. Clinicians should use this information to engage in open discussion with patients to promote adherence and identify barriers and facilitators within their own populations.
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Affiliation(s)
- Edward J Mills
- Centre for International Health and Human Rights Studies, Toronto, Ontario, Canada.
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Mills EJ, Nachega JB, Buchan I, Orbinski J, Attaran A, Singh S, Rachlis B, Wu P, Cooper C, Thabane L, Wilson K, Guyatt GH, Bangsberg DR. Adherence to antiretroviral therapy in sub-Saharan Africa and North America: a meta-analysis. JAMA 2006; 296:679-90. [PMID: 16896111 DOI: 10.1001/jama.296.6.679] [Citation(s) in RCA: 678] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Adherence to antiretroviral therapy is a powerful predictor of survival for individuals living with human immunodeficiency virus (HIV) and AIDS. Concerns about incomplete adherence among patients living in poverty have been an important consideration in expanding the access to antiretroviral therapy in sub-Saharan Africa. OBJECTIVE To evaluate estimates of antiretroviral therapy adherence in sub-Saharan Africa and North America. DATA SOURCES Eleven electronic databases were searched along with major conference abstract databases (inclusion dates: inception of database up until April 18, 2006) for all English-language articles and abstracts; and researchers and treatment advocacy groups were contacted. Study Selection and Data Abstraction To best reflect the general population, studies of mixed populations in both North America and Africa were selected. Studies evaluating specific populations such as men only, homeless individuals, or drug users, were excluded. The data were abstracted in duplicate on study adherence outcomes, thresholds used to determine adherence, and characteristics of the populations. A random-effects meta-analysis was performed in which heterogeneity was examined using multivariable random-effects logistic regression. A sensitivity analysis was performed using Bayesian methods. DATA SYNTHESIS Thirty-one studies from North America (28 full-text articles and 3 abstracts) and 27 studies (9 full-text articles and 18 abstracts) from sub-Saharan Africa were included. African studies represented 12 sub-Saharan countries. Of the North American studies, 71% used patient self-report to assess adherence; this was true of 66% of the African assessments. Studies reported similar thresholds for adherence monitoring (eg, 100%, >95%, >90%, >80%). A pooled analysis of the North American studies (17,573 patients total) indicated a pooled estimate of 55% (95% confidence interval, 49%-62%; I2, 98.6%) of the populations achieving adequate levels of adherence. Our pooled analysis of African studies (12,116 patients total) indicated a pooled estimate of 77% (95% confidence interval, 68%-85%; I2, 98.4%). Study continent, adherence thresholds, and study quality were significant predictors of heterogeneity. Bayesian analysis was used as an alternative statistical method for combining adherence rates and provided similar findings. CONCLUSION Our findings indicate that favorable levels of adherence, much of which was assessed via patient self-report, can be achieved in sub-Saharan African settings and that adherence remains a concern in North America.
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Affiliation(s)
- Edward J Mills
- Centre for International Health and Human Rights Studies, Toronto, Ontario, Canada.
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Mills EJ, Seely D, Rachlis B, Griffith L, Wu P, Wilson K, Ellis P, Wright JR. Barriers to participation in clinical trials of cancer: a meta-analysis and systematic review of patient-reported factors. Lancet Oncol 2006; 7:141-8. [PMID: 16455478 DOI: 10.1016/s1470-2045(06)70576-9] [Citation(s) in RCA: 378] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Enrolling participants onto clinical trials of cancer presents an important challenge. We aimed to identify the concerns of patients with cancer about, and the barriers to, participation in clinical trials. METHODS We did a systematic review to assess studies of barriers to participation in experimental trials and randomised trials for validity and content. We estimated the frequency with which patients identified particular issues by pooling across studies that presented data for barriers to participation in clinical trials as proportions. FINDINGS We analysed 12 qualitative studies (n=722) and 21 quantitative studies (n=5452). Two qualitative studies inquired of patients who were currently enrolled onto clinical trials, and ten inquired of patients who were eligible for enrolment onto various clinical trials. Barriers to participation in clinical trials were protocol-related, patient-related, or physician-related. The most common reasons cited as barriers included: concerns with the trial setting; a dislike of randomisation; general discomfort with the research process; complexity and stringency of the protocol; presence of a placebo or no-treatment group; potential side-effects; being unaware of trial opportunities; the idea that clinical trials are not appropriate for serious diseases; fear that trial involvement would have a negative effect on the relationship with their physician; and their physician's attitudes towards the trial. Meta-analysis confirmed the findings of our systematic review. INTERPRETATION The identification of such barriers to the participation in clinical trials should help trialists to develop strategies that will keep to a maximum participation and cooperation in cancer trials, while informing and protecting prospective participants adequately.
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Affiliation(s)
- Edward J Mills
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
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Mills E, Wilson K, Rachlis B, Griffith L, Wu P, Guyatt G, Cooper C. Barriers to participation in HIV drug trials: a systematic review. The Lancet Infectious Diseases 2006; 6:32-8. [PMID: 16377532 DOI: 10.1016/s1473-3099(05)70324-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The enrolling of adequate participants into HIV experimental drug trials presents an important challenge. We systematically reviewed the literature to identify barriers and concerns amongst HIV patients to participation in HIV clinical drug trials. We reviewed studies for validity and content, and generated pooled estimates of the frequency with which patients identified particular issues by pooling across studies that presented results as proportions. We included three semi-structured interview studies, two open-ended questionnaires, and nine quantitative studies. Major barriers to participation included fear of side-effects, distrust of researchers, general concerns about research design, interference in everyday life or changes in routine, and social discrimination. Results from the quantitative studies indicated that the most prevalent barriers were as follows: suspicions about the drug itself (53%, 95% CI 24-83%), patients were not informed or believed they were not eligible (38%, 25-50%), and travel or transport obstacles (39%, 21-57%). The findings of this study should aid drug trialists in developing strategies to maximise participation and cooperation in HIV clinical drug trials while adequately informing and protecting prospective participants.
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Affiliation(s)
- Edward Mills
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
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Mills E, Rachlis B, Wu P, Wong E, Wilson K, Singh S. Media reporting of tenofovir trials in Cambodia and Cameroon. BMC Int Health Hum Rights 2005; 5:6. [PMID: 16120208 PMCID: PMC1242229 DOI: 10.1186/1472-698x-5-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/19/2005] [Accepted: 08/24/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Two planned trials of pre-exposure prophylaxis tenofovir in Cambodia and Cameroon to prevent HIV infection in high-risk populations were closed due to activist pressure on host country governments. The international news media contributed substantially as the primary source of knowledge transfer regarding the trials. We aimed to characterize the nature of reporting, specifically focusing on the issues identified by media reports regarding each trial. METHODS With the aid of an information specialist, we searched 3 electronic media databases, 5 electronic medical databases and extensively searched the Internet. In addition we contacted stakeholder groups. We included media reports addressing the trial closures, the reasons for the trial closures, and who was interviewed. We extracted data using content analysis independently, in duplicate. RESULTS We included 24 reports on the Cambodian trial closure and 13 reports on the Cameroon trial closure. One academic news account incorrectly reported that it was an HIV vaccine trial that closed early. The primary reasons cited for the Cambodian trial closure were: a lack of medical insurance for trial related injuries (71%); human rights considerations (71%); study protocol concerns (46%); general suspicions regarding trial location (37%) and inadequate prevention counseling (29%). The primary reasons cited for the Cameroon trial closure were: inadequate access to care for seroconverters (69%); participants not sufficiently informed of risks (69%); inadequate number of staff (46%); participants being exploited (46%) and an unethical study design (38%). Only 3/23 (13%) reports acknowledged interviewing research personnel regarding the Cambodian trial, while 4/13 (30.8%) reports interviewed researchers involved in the Cameroon trial. CONCLUSION Our review indicates that the issues addressed and validity of the media reports of these trials is highly variable. Given the potential impact of the media in formulation of health policy related to HIV, efforts are needed to effectively engage the media during periods of controversy in the HIV/AIDS epidemic.
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Affiliation(s)
- Edward Mills
- Dept. of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
- Centre for International Human Rights Law, University of Oxford, Oxford, UK
| | - Beth Rachlis
- Dept. of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Ping Wu
- Department of Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Elaine Wong
- Development Studies Institute, London School of Economics, London, UK
| | - Kumanan Wilson
- Departments of Medicine, Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Sonal Singh
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
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Mills E, Wilson K, Clarke M, Foster B, Walker S, Rachlis B, DeGroot N, Montori VM, Gold W, Phillips E, Myers S, Gallicano K. Milk thistle and indinavir: a randomized controlled pharmacokinetics study and meta-analysis. Eur J Clin Pharmacol 2005; 61:1-7. [PMID: 15666173 DOI: 10.1007/s00228-004-0843-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2004] [Accepted: 09/22/2004] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To determine whether ingestion of milk thistle affects the pharmacokinetics of indinavir. METHODS We conducted a three-period, randomized controlled trial with 16 healthy participants. We randomized participants to milk thistle or control. All participants received initial dosing of indinavir, and baseline indinavir levels were obtained (AUC(0-8)) (phase I). The active group were then given 450 mg milk-thistle extract capsules to be taken t.i.d. from day 2 to day 30. The control group received no plant extract. On day 29 and day 30, indinavir dosing and sampling was repeated in both groups as before (phase II). After a wash-out period of 7 days, indinavir dosing and sampling were repeated as before (phase III). RESULTS All participants completed the trial, but two were excluded from analysis due to protocol violation. There were no significant between-group differences. Active group mean AUC(0-8) indinavir decreased by 4.4% (90% CI, -27.5% to -26%, P=0.78) from phase I to phase II in the active group, and by 17.3% (90% CI, -37.3% to +9%, P=0.25) in phase III. Control group mean AUC(0-8) decreased by 21.5% (90% CI, -43% to +8%, P=0.2) from phase I to phase II and by 38.5% (90% CI, -55.3% to -15.3%, P=0.01) of baseline at phase III. To place our findings in context, milk thistle-indinavir trials were identified through systematic searches of the literature. A meta-analysis of three milk thistle-indinavir trials revealed a non-significant pooled mean difference of 1% in AUC(0-8) (95% CI, -53% to 55%, P=0.97). CONCLUSIONS Indinavir levels were not reduced significantly in the presence of milk thistle.
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Affiliation(s)
- Edward Mills
- Faculty of Health Sciences, Clinical Epidemiology and Biostatistics, McMaster University, HSC-2C12, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada.
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