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Janjua NZ, Islam N, Wong J, Yoshida EM, Ramji A, Samji H, Butt Z, Chong M, Alvarez M, Cook D, Tyndall M, Krajden M. A162 SHIFT IN DISPARITIES IN HCV TREATMENT FROM INTERFERON TO DAA ERA: A POPULATION BASED COHORT STUDY. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy008.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- N Z Janjua
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - N Islam
- Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - J Wong
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - E M Yoshida
- Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - A Ramji
- Gastrointestinal Research Institute, Vancouver, BC, Canada
| | - H Samji
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Z Butt
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - M Chong
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - M Alvarez
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - D Cook
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - M Tyndall
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - M Krajden
- BC Centre for Disease Control, Vancouver, BC, Canada
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Janjua NZ, Islam N, Wong J, Yoshida EM, Ramji A, Samji H, Butt ZA, Chong M, Cook D, Alvarez M, Darvishian M, Tyndall M, Krajden M. Shift in disparities in hepatitis C treatment from interferon to DAA era: A population-based cohort study. J Viral Hepat 2017; 24:624-630. [PMID: 28130810 DOI: 10.1111/jvh.12684] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [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: 11/01/2016] [Accepted: 12/22/2016] [Indexed: 12/15/2022]
Abstract
We evaluated the shift in the characteristics of people who received interferon-based hepatitis C virus (HCV) treatments and those who received recently introduced direct-acting antivirals (DAAs) in British Columbia (BC), Canada. The BC Hepatitis Testers Cohort includes 1.5 million individuals tested for HCV or HIV, or reported cases of hepatitis B and active tuberculosis in BC from 1990 to 2013 linked to medical visits, hospitalization, cancer, prescription drugs and mortality data. This analysis included all patients who filled at least one prescription for HCV treatment until 31 July 2015. HCV treatments were classified as older interferon-based treatments including pegylated interferon/ribavirin (PegIFN/RBV) with/without boceprevir or telaprevir, DAAs with RBV or PegIFN/RBV, and newer interferon-free DAAs. Of 11 886 people treated for HCV between 2000 and 2015, 1164 (9.8%) received interferon-free DAAs (ledipasvir/sofosbuvir: n=1075; 92.4%), while 452 (3.8%) received a combination of DAAs and RBV or PegIFN/RBV. Compared to those receiving interferon-based treatment, people with HIV co-infection (adjusted odds ratio [aOR]: 2.96, 95% CI: 2.31-3.81), cirrhosis (aOR: 1.77, 95% CI: 1.45-2.15), decompensated cirrhosis (aOR: 1.72, 95% CI: 1.31-2.28), diabetes (aOR: 1.30, 95% CI: 1.10-1.54), a history of injection drug use (aOR: 1.34, 95% CI: 1.09-1.65) and opioid substitution therapy (aOR: 1.30, 95% CI: 1.01-1.67) were more likely to receive interferon-free DAAs. Socio-economically marginalized individuals were significantly less likely (most deprived vs most privileged: aOR: 0.71, 95% CI: 0.58-0.87) to receive DAAs. In conclusion, there is a shift in prescription of new HCV treatments to previously excluded groups (eg HIV-co-infected), although gaps remain for the socio-economically marginalized populations.
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Affiliation(s)
- N Z Janjua
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - N Islam
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - J Wong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - E M Yoshida
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - A Ramji
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - H Samji
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Z A Butt
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M Chong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - D Cook
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - M Alvarez
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - M Darvishian
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M Tyndall
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M Krajden
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
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Boucher LM, Marshall Z, Martin A, Larose-Hébert K, Flynn JV, Lalonde C, Pineau D, Bigelow J, Rose T, Chase R, Boyd R, Tyndall M, Kendall C. Expanding conceptualizations of harm reduction: results from a qualitative community-based participatory research study with people who inject drugs. Harm Reduct J 2017; 14:18. [PMID: 28494774 PMCID: PMC5427533 DOI: 10.1186/s12954-017-0145-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [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: 12/07/2016] [Accepted: 03/30/2017] [Indexed: 12/04/2022] Open
Abstract
Background The perspectives of people who use drugs are critical in understanding why people choose to reduce harm in relation to drug use, what practices are considered or preferred in conceptualizations of harm reduction, and which environmental factors interfere with or support the use of harm reduction strategies. This study explores how people who inject drugs (PWID) think about harm reduction and considers the critical imperative of equity in health and social services delivery for this community. Methods This community-based participatory research study was conducted in a Canadian urban centre. Using a peer-based recruitment and interviewing strategy, semi-structured qualitative interviews were conducted by and with PWID. The Vidaview Life Story Board, an innovative tool where interviewers and participant co-construct a visual “life-scape” using a board, markers, and customized picture magnets, was used to facilitate the interviews. The topics explored included injection drug use and harm reduction histories, facilitators and barriers to using harm reduction strategies, and suggestions for improving services and supports. Results Twenty-three interviews with PWID (14 men and 9 women) were analysed, with a median age of 50. Results highlighted an expanded conceptualization of harm reduction from the perspectives of PWID, including motivations for adopting harm reduction strategies and a description of harm reduction practices that went beyond conventional health-focused concerns. The most common personal practices that PWID used included working toward moderation, employing various cognitive strategies, and engaging in community activities. The importance of social or peer support and improving self-efficacy was also evident. Further, there was a call for less rigid eligibility criteria and procedures in health and social services, and the need to more adequately address the stigmatization of drug users. Conclusions These findings demonstrated that PWID incorporate many personal harm reduction practices in their daily lives to improve their well-being, and these practices highlight the importance of agency, self-care, and community building. Health and social services are needed to better support these practices because the many socio-structural barriers this community faces often interfere with harm reduction efforts. Finally, “one size does not fit all” when it comes to harm reduction, and more personalized or de-medicalized conceptualizations are recommended.
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Affiliation(s)
- L M Boucher
- Élisabeth Bruyère Research Institute, 43 Bruyère Street, Annex E, Ottawa, Ontario, K1N 5C8, Canada.
| | - Z Marshall
- Social Development Studies & School of Social Work, Renison University College, University of Waterloo, 240 Westmount Road North, Waterloo, Ontario, N2L 3G4, Canada
| | - A Martin
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada
| | - K Larose-Hébert
- School of Social Work, Faculty of Social Sciences, Laval University, Charles de Koninck Hall, 1030, avenue des Sciences-Humaines, Quebec, G1V 0A6, Canada
| | - J V Flynn
- Department of Social Work, University of Gothenburg, Sprängkullsgatan 23, 405 30, Gothenburg, Sweden
| | - C Lalonde
- PROUD Community Advisory Committee, Ottawa, Ontario, Canada
| | - D Pineau
- PROUD Community Advisory Committee, Ottawa, Ontario, Canada
| | - J Bigelow
- PROUD Community Advisory Committee, Ottawa, Ontario, Canada
| | - T Rose
- PROUD Community Advisory Committee, Ottawa, Ontario, Canada
| | - R Chase
- Department of Community Health Sciences, Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, Manitoba, R3E 0W2, Canada
| | - R Boyd
- Sandy Hill Community Health Centre, 221 Nelson Street, Ottawa, Ontario, K1N 1C7, Canada
| | - M Tyndall
- BC Centre for Disease Control, 655 W 12th Avenue, Vancouver, British Columbia, V5Z 4R4, Canada
| | - C Kendall
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, 43 Bruyère Street, (375) Floor 3JB, Ottawa, Ontario, K1N 5C8, Canada
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Islam N, Krajden M, Gilbert M, Gustafson P, Yu A, Kuo M, Chong M, Alvarez M, Wong J, Tyndall MW, Janjua NZ. Role of primary T-cell immunodeficiency and hepatitis B coinfection on spontaneous clearance of hepatitis C: The BC Hepatitis Testers Cohort. J Viral Hepat 2017; 24:421-429. [PMID: 27885757 DOI: 10.1111/jvh.12650] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 06/24/2016] [Accepted: 10/29/2016] [Indexed: 12/13/2022]
Abstract
T-cell host immune response against hepatitis C virus (HCV) has been suggested to play an important role in determining HCV infection outcome. However, data from human studies are not available. This study examined the effect of primary T-cell deficiency along with other factors on the spontaneous clearance of HCV in a large population-based cohort in British Columbia, Canada. The BC Hepatitis Testers Cohort includes all individuals tested for HCV in BC in 1990-2013 linked with data on their medical visits, hospitalizations and prescription drugs. HCV-positive individuals with at least one valid HCV PCR test on/after HCV diagnosis (n=46 783) were included in this study. To examine factors associated with the spontaneous clearance of HCV, multivariable logistic regression was fitted on the full sample, and Cox proportional hazards model on the HCV seroconverters. Spontaneous clearance was observed in 25.1% (n=11 737) of those tested for HCV. After adjusting for potential confounders, the odds of spontaneous clearance of HCV was lower in people with primary T-cell immunodeficiency (adjusted odds ratio [aOR]: 0.55, 95% CI: 0.32-0.94), and higher in females (aOR: 1.61, 95% CI: 1.54-1.68) and in those coinfected with HBV (aOR: 2.31, 95% CI: 1.93-2.77). Similar results were observed in HCV seroconverters except HBV coinfection was not significant. In conclusion, primary T-cell immunodeficiency is associated with a lower spontaneous clearance of HCV while female sex and coinfection with HBV are associated with a higher spontaneous clearance.
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Affiliation(s)
- N Islam
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - M Krajden
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - M Gilbert
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,Ontario HIV Treatment Network, Toronto, ON, Canada
| | - P Gustafson
- Department of Statistics, University of British Columbia, Vancouver, BC, Canada
| | - A Yu
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - M Kuo
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - M Chong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - M Alvarez
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - J Wong
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - M W Tyndall
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - N Z Janjua
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,British Columbia Centre for Disease Control, Vancouver, BC, Canada
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Cooper C, Rollet-Kurhajec KC, Young J, Vasquez C, Tyndall M, Gill J, Pick N, Walmsley S, Klein MB. HIV virological rebounds but not blips predict liver fibrosis progression in antiretroviral-treated HIV/hepatitis C virus-coinfected patients. HIV Med 2014; 16:24-31. [PMID: 24837567 PMCID: PMC4312483 DOI: 10.1111/hiv.12168] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [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] [Accepted: 04/09/2014] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Antiretroviral interruption is associated with liver fibrosis progression in HIV/hepatitis C virus (HCV) coinfection. It is not known what level of HIV viraemia affects fibrosis progression. METHODS We evaluated 288 HIV/HCV-coinfected cohort participants with undetectable HIV RNA (<50 HIV-1 RNA copies/mL) on two consecutive visits while on combination antiretroviral therapy (cART) without fibrosis [aspartate aminotransferase to platelet ratio index (APRI) <1.5], end-stage liver disease or HCV therapy. An HIV blip was defined as a viral load of ≥ 50 and <1000 copies/mL, preceded and followed by undetectable values. HIV rebound was defined as: (i) HIV RNA ≥ 50 copies/mL on two consecutive visits, or (ii) a single HIV RNA measurement ≥ 1000 copies/mL. Multivariate discrete-time proportional hazards models were used to assess the effect of different viraemia levels on liver fibrosis progression (APRI ≥ 1.5). RESULTS The mean age of the patients was 45 years, 74% were male, 81% reported a history of injecting drug use, 51% currently used alcohol and the median baseline CD4 count was 440 [interquartile range (IQR) 298, 609] cells/μL. Fifty-seven (20%) participants [12.4/100 person-years (PY); 95% confidence interval (CI) 9.2-15.7/100 PY] progressed to an APRI ≥ 1.5 over a mean 1.1 (IQR 0.6, 2.0) years of follow-up time at risk. Virological rebound [hazard ratio (HR) 2.3; 95% CI 1.1, 4.7] but not blips (HR 0.5; 95% CI 0.2, 1.1) predicted progression to APRI ≥ 1.5. Each additional 1 log10 copies/mL HIV RNA exposure (cumulative) was associated with a 20% increase in the risk of fibrosis progression (HR 1.2; 95% CI 1.0-1.3). CONCLUSIONS Liver fibrosis progression was associated with HIV rebound, but not blips, and with increasing cumulative exposure to HIV RNA, highlighting the importance of achieving and maintaining HIV suppression in the setting of HIV/HCV coinfection.
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Affiliation(s)
- C Cooper
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Canadian Institutes of Health Research Canadian HIV Trials Network, Vancouver, BC, Canada
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Klein MB, Rollet KC, Saeed S, Cox J, Potter M, Cohen J, Conway B, Cooper C, Côté P, Gill J, Haase D, Haider S, Hull M, Moodie E, Montaner J, Pick N, Rachlis A, Rouleau D, Sandre R, Tyndall M, Walmsley S. HIV and hepatitis C virus coinfection in Canada: challenges and opportunities for reducing preventable morbidity and mortality. HIV Med 2012; 14:10-20. [PMID: 22639840 DOI: 10.1111/j.1468-1293.2012.01028.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2012] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Hepatitis C virus (HCV) has emerged as an important health problem in the era of effective HIV treatment. However, very few data exist on the health status and disease burden of HIV/HCV-coinfected Canadians. METHODS HIV/HCV-coinfected patients were enrolled prospectively in a multicentre cohort from 16 centres across Canada between 2003 and 2010 and followed every 6 months. We determined rates of a first liver fibrosis or endstage liver disease (ESLD) event and all-cause mortality since cohort enrolment and calculated standardized mortality ratios compared with the general Canadian population. RESULTS A total of 955 participants were enrolled in the study and followed for a median of 1.4 (interquartile range 0.5-2.3) years. Most were male (73%) with a median age of 44.5 years; 13% self-identified as aboriginal. There were high levels of current injecting drug and alcohol use and poverty. Observed event rates [per 100 person-years; 95% confidence interval (CI)] were: significant fibrosis (10.21; 8.49, 12.19), ESLD (3.16; 2.32, 4.20) and death (3.72; 2.86, 4.77). The overall standardized mortality ratio was 17.08 (95% CI 12.83, 21.34); 12.80 (95% CI 9.10, 16.50) for male patients and 28.74 (95% CI 14.66, 42.83) for female patients. The primary causes of death were ESLD (29%) and overdose (24%). CONCLUSIONS We observed excessive morbidity and mortality in this HIV/HCV-coinfected population in care. Over 50% of observed deaths may have been preventable. Interventions aimed at improving social circumstances, reducing harm from drug and alcohol use and increasing the delivery of HCV treatment in particular will be necessary to reduce adverse health outcomes among HIV/HCV-coinfected persons.
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Affiliation(s)
- M B Klein
- Department of Medicine, Divisions of Infectious Diseases/Immunodeficiency, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada.
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7
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Davenport WB, Lowe MP, Chamberlin DH, Kamelle SA, Johnson PR, Tyndall M, Tillmanns TD. Outcomes of obese versus non-obese subjects undergoing robotic-assisted hysterectomy: a multi-institutional study. J Robot Surg 2012; 7:15-20. [DOI: 10.1007/s11701-011-0333-0] [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] [Received: 10/21/2011] [Accepted: 12/14/2011] [Indexed: 11/24/2022]
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Deering KN, Shoveller J, Tyndall MW, Montaner JS, Shannon K. The street cost of drugs and drug use patterns: relationships with sex work income in an urban Canadian setting. Drug Alcohol Depend 2011; 118:430-6. [PMID: 21704461 PMCID: PMC3392208 DOI: 10.1016/j.drugalcdep.2011.05.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [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: 12/23/2010] [Revised: 05/02/2011] [Accepted: 05/03/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study investigated the relationship between drug use and sex work patterns and sex work income earned among street-based female sex workers (FSWs) in Vancouver, Canada. METHODS We used data from a sample of 129 FSWs who used drugs in a prospective cohort (2007-2008), for a total of 210 observations. Bivariate and multivariable linear regression using generalized estimating equations was used to model the relationship between explanatory factors and sex work income. Sex work income was log-transformed to account for skewed data. RESULTS The median age of the sample at first visit was 37 years (interquartile range[IQR]: 30-43), with 46.5% identifying as Caucasian, 48.1% as Aboriginal and 5.4% as another visible minority. The median weekly sex work income and amount spent on drugs was $300 (IQR=$100-$560) and $400 (IQR=$150-$780), respectively. In multivariable analysis, for a 10% increase in money spent on drugs, sex work income increased by 1.9% (coeff: 0.20, 95% CIs: 0.04-0.36). FSWs who injected heroin, FSWs with higher numbers of clients and youth compared to older women (<25 versus 25+ years) also had significantly higher sex work income. CONCLUSIONS This study highlights the important role that drug use plays in contributing to increased dependency on sex work for income among street-based FSWs in an urban Canadian setting, including a positive dose-response relationship between money spent on drugs and sex work income. These findings indicate a crucial need to scale up access and availability of evidence-based harm reduction and treatment approaches, including policy reforms, improved social support and economic choice for vulnerable women.
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Affiliation(s)
- KN Deering
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
,School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, CANADA, V6T 1Z3
| | - J Shoveller
- School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, CANADA, V6T 1Z3
| | - MW Tyndall
- Division of Infectious Diseases, Faculty of Medicine, University of Ottawa 501 Smyth Road, Ottawa, ON, CANADA K1H 8L6
| | - JS Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
,Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
| | - K Shannon
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
,School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, CANADA, V6T 1Z3
,Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
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Miller CL, Fielden SJ, Tyndall MW, Zhang R, Gibson K, Shannon K. Individual and structural vulnerability among female youth who exchange sex for survival. J Adolesc Health 2011; 49:36-41. [PMID: 21700154 PMCID: PMC3392207 DOI: 10.1016/j.jadohealth.2010.10.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [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: 04/22/2010] [Revised: 10/08/2010] [Accepted: 10/10/2010] [Indexed: 02/06/2023]
Abstract
PURPOSE Because of growing concerns regarding the heightened vulnerabilities and risk of human immunodeficiency virus infection among youth who exchange sex for survival, we investigated individual risk patterns and structural barriers among young (≤24 years) female sex workers (FSWs) in Vancouver, Canada. METHODS Between 2005 and 2008, a total of 255 street-based FSWs (≥14 years) were enrolled into a community-based prospective cohort, and were asked to participate in baseline and biannual questionnaires administered through interviews and human immunodeficiency virus screening. We used contingency table analysis to compare individual and structural barrier results obtained at baseline for younger (≤24 years) FSWs with those of the older (>25 years) FSWs. For longitudinal data, we used generalized estimating equations throughout the follow-up period to determine factors associated with being a young FSW in the past 6 months. RESULTS In comparison with older FSWs (n = 199), youth (n = 56) were more likely to spend fewer years engaging in sex exchange (median: 6.4 [interquartile range: 4.6-9.1] vs. 19.9 [interquartile range: 10.0-26.8]; p ≤ .001), belong to an aboriginal ancestry (59% vs. 44%; p = .052), and be homeless (68% vs. 36%; p ≤ .001). In the multivariate generalized estimating equations analysis, youth reported a significantly elevated proportional odds of being homeless (odds ratio [OR]: 1.26 [confidence interval {CI}: 1.08-1.48]), servicing clients in public places (OR: 1.28 [CI: 1.04-1.57]), injecting heroin on a daily basis (OR: 1.35 [CI: 1.06-1.74]), and a significantly reduced odds of accessing methadone maintenance therapy (OR: .76 [CI: .62-.93]). CONCLUSIONS This study demonstrates significant displacement of youth who engage in sex exchange to marginalized working and living spaces. The findings of this study bring to attention the critical need for targeted structural interventions including access to youth and gender-specific social housing, safe working spaces, reduction in the amount of harm caused to them, and addiction treatment services for youth engaged in survival sex work.
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Affiliation(s)
- CL Miller
- Simon Fraser University, Burnaby, British Columbia, Canada
| | - SJ Fielden
- Faculty of Health Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - MW Tyndall
- Faculty of Health Sciences, University of British Columbia, Vancouver, British Columbia, Canada,British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - R Zhang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - K Gibson
- Women’s Information Safe Haven (WISH) Drop-In Centre Society, Vancouver, British Columbia, Canada
| | - K Shannon
- Faculty of Health Sciences, University of British Columbia, Vancouver, British Columbia, Canada,British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
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10
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Shannon K, Strathdee SA, Shoveller J, Zhang R, Montaner JS, Tyndall MW. Crystal methamphetamine use among female street-based sex workers: Moving beyond individual-focused interventions. Drug Alcohol Depend 2011; 113:76-81. [PMID: 20810223 PMCID: PMC3392206 DOI: 10.1016/j.drugalcdep.2010.07.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [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: 01/27/2010] [Revised: 07/21/2010] [Accepted: 07/26/2010] [Indexed: 11/16/2022]
Abstract
Given growing concern of the sexual risks associated with crystal methamphetamine use and the dearth of research characterizing the use of methamphetamine among street-based sex workers (FSWs), this study aimed to characterize the prevalence and individual, social, and structural contexts of crystal methamphetamine use among FSWs in a Canadian setting. Drawing on data from a prospective cohort, we constructed multivariate logistic models to examine independent correlates of crystal methamphetamine among FSWs over a two-year follow-up period using generalized estimating equations. Of a total of 255 street-based FSWs, 78 (32%) reported lifetime crystal methamphetamine use and 24% used crystal methamphetamine during the two-year follow-up period, with no significant associations between methamphetamine use and sexual risk patterns. In a final multivariate GEE model, FSWs who used crystal methamphetamine had a higher proportional odds of dual heroin injection (adjOR=2.98, 95%CI: 1.35-5.22), having a primary male sex partner who procures drugs for them (adjOR=1.79, 95%CI: 1.02-3.14), and working (adjOR=1.62, 95%CI: 1.04-2.65) and living (adjOR=1.41, 95%CI: 1.07-1.99) in marginalized public spaces. The findings highlight the crucial need to move beyond the individual to gender-focused safer environment interventions that mediate the physical and social risk environment of crystal methamphetamine use among FSWs.
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Affiliation(s)
- K Shannon
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6,School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, CANADA, V6T 1Z3
| | - SA Strathdee
- Centre for Global Public Health, University of California San Diego School of Medicine, La Jolla, CA 92093-0507, United States
| | - J Shoveller
- School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, CANADA, V6T 1Z3
| | - R Zhang
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
| | - JS Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
| | - MW Tyndall
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
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Grebely J, Raffa JD, Lai C, Kerr T, Fischer B, Krajden M, Dore GJ, Tyndall MW. Impact of hepatitis C virus infection on all-cause and liver-related mortality in a large community-based cohort of inner city residents. J Viral Hepat 2011; 18:32-41. [PMID: 20196806 DOI: 10.1111/j.1365-2893.2010.01279.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [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: 12/13/2022]
Abstract
The aim of this study was to measure the impact of hepatitis C virus (HCV) infection on mortality in a cohort of inner city residents. The Community Health and Safety Evaluation is a community-based study of inner city residents followed retrospectively and prospectively through linkages with provincial virology and mortality databases. We identified participants having received HCV antibody testing, evaluated cause-specific mortality rates and factors associated with all-cause and liver-related mortality using Cox Proportional Hazards models. Overall, 2332 participants received HCV antibody testing (recent non-injection drug use - 81%). The prevalence of HCV and HIV was 64% (1495 of 2332) and 21% (485 of 2332), respectively. Between January 2003 and December 2007, there were 180 deaths (192 per 10.000 person-years; 95% CI: 165, 222), with 21% HIV-related, 20% drug-related and 7% liver-related. Mortality was associated with age >50 [adjusted hazard ratio (AHR) 2.80 vs < 40 years (referent group); 95% CI 1.93, 4.07, P < 0.001] and HIV infection (AHR 3.81; 95% CI 2.72, 5.34, P < 0.001), but not positive HCV antibody status (AHR 1.19; 95% CI 0.83, 1.72, P = 0.35). Liver-related mortality was associated with age >50 [AHR 18.49 vs < 40 years (referent group); 95% CI 2.27, 150.41, P < 0.001] and positive HCV antibody status (AHR 7.69; 95% CI 0.99, 59.98, P = 0.052). This study demonstrates a high rate of mortality in this population, particularly those with HIV. HCV-infected inner city residents >50 years of age were at significant risk of liver-related mortality. Continued surveillance of this population infected with HCV in the 1970s and 1980s is important.
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Affiliation(s)
- J Grebely
- National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, NSW, Australia.
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Shannon K, Kerr T, Strathdee SA, Shoveller J, Montaner JS, Tyndall MW. Prevalence and structural correlates of gender based violence among a prospective cohort of female sex workers. BMJ 2009; 339:b2939. [PMID: 19671935 PMCID: PMC2725271 DOI: 10.1136/bmj.b2939] [Citation(s) in RCA: 202] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To examine the prevalence and structural correlates of gender based violence against female sex workers in an environment of criminalised prostitution. DESIGN Prospective observational study. SETTING Vancouver, Canada during 2006-8. PARTICIPANTS Female sex workers 14 years of age or older (inclusive of transgender women) who used illicit drugs (excluding marijuana) and engaged in street level sex work. MAIN OUTCOME MEASURE Self reported gender based violence. RESULTS Of 267 female sex workers invited to participate, 251 women returned to the study office and consented to participate (response rate of 94%). Analyses were based on 237 female sex workers who completed a baseline visit and at least one follow-up visit. Of these 237 female sex workers, 57% experienced gender based violence over an 18 month follow-up period. In multivariate models adjusted for individual and interpersonal risk practices, the following structural factors were independently correlated with violence against female sex workers: homelessness (adjusted odds ratio for physical violence (aOR(physicalviolence)) 2.14, 95% confidence interval 1.34 to 3.43; adjusted odds ratio for rape (aOR(rape)) 1.73, 1.09 to 3.12); inability to access drug treatment (adjusted odds ratio for client violence (aOR(clientviolence)) 2.13, 1.26 to 3.62; aOR(physicalviolence) 1.96, 1.03 to 3.43); servicing clients in cars or public spaces (aOR(clientviolence) 1.50, 1.08 to 2.57); prior assault by police (aOR(clientviolence) 3.45, 1.98 to 6.02; aOR(rape) 2.61, 1.32 to 5.16); confiscation of drug use paraphernalia by police without arrest (aOR(physicalviolence) 1.50, 1.02 to 2.41); and moving working areas away from main streets owing to policing (aOR(clientviolence) 2.13, 1.26 to 3.62). CONCLUSIONS Our results demonstrate an alarming prevalence of gender based violence against female sex workers. The structural factors of criminalisation, homelessness, and poor availability of drug treatment independently correlated with gender based violence against street based female sex workers. Socio-legal policy reforms, improved access to housing and drug treatment, and scale up of violence prevention efforts, including police-sex worker partnerships, will be crucial to stemming violence against female sex workers.
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Affiliation(s)
- Kate Shannon
- British Columbia Centre for Excellence in HIV/AIDS St Paul's Hospital, Vancouver, BC V6Z 1Y6, Canada.
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13
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Grebely J, Raffa JD, Lai C, Krajden M, Kerr T, Fischer B, Tyndall MW. Low uptake of treatment for hepatitis C virus infection in a large community-based study of inner city residents. J Viral Hepat 2009; 16:352-8. [PMID: 19226330 DOI: 10.1111/j.1365-2893.2009.01080.x] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [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: 12/13/2022]
Abstract
Despite the availability of effective therapy for hepatitis C virus (HCV) infection, there are little data on the uptake of treatment. We evaluated factors associated with HCV infection and the uptake of HCV treatment in a large community-based inner city cohort in Vancouver, Canada. The Community Health and Safety Evaluation is a cohort study of inner city residents recruited from January 2003 to June 2004. HIV and HCV status and information on prescriptions for HCV treatment were determined through linkage with provincial databases. HCV prevalence was calculated and factors associated with HCV infection were identified. HCV treatment uptake and incidence of HCV infection from January 2000 to December 2004 were expressed in terms of person-years of observation. Among 2913 individuals, HCV antibody testing was performed in 2118 and the HCV seroprevalence was 64.2% (1360 of 2118). In total, 1.1% of HCV antibody-positive individuals (15 of 1360) initiated treatment for HCV infection from January 2000 to December 2004 [0.28 cases per 100 person-years (95% CI, 0.15-0.46)]. Three of 15 (20.0%) treated individuals achieved a sustained virological response. During the same period, the incidence of HCV infection was 7.26 cases (95% CI, 5.72-8.80) per 100 person-years. Overall, the rate of new HCV seroconversions in this cohort in the study period was about 25 times the rate of HCV treatment uptake. There are extremely low rates of HCV treatment initiation and very limited effectiveness, despite a high prevalence of HCV infection in this large community-based cohort of inner city residents with access to universal healthcare.
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Affiliation(s)
- J Grebely
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, NSW, Australia.
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Marshall BDL, Wood E, Zhang R, Tyndall MW, Montaner JSG, Kerr T. Condom use among injection drug users accessing a supervised injecting facility. Sex Transm Infect 2008; 85:121-6. [PMID: 18812391 DOI: 10.1136/sti.2008.032524] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Although supervised injecting facility (SIF) use has been associated with reductions in injection-related risk behaviours, the impact of SIFs on the sexual behaviour of injection drug users (IDUs) has not been thoroughly investigated. Therefore, we examined the patterns and predictors of condom use among SIF users in Vancouver, Canada. METHODS We performed a longitudinal analysis of the factors associated with consistent condom use among IDUs recruited from within a SIF. RESULTS Among 1090 individuals, 650 (59.6%) reported a sexual partner in the past 6 months at baseline. Consistent condom use was reported by 108 (25.3%) and 205 (61.6%) individuals reporting regular or casual partners, respectively. After 2 years of observation, these proportions increased to 32.9% and 69.8%, respectively. In multivariate analysis, predictors of consistent condom use with regular partners included HIV positivity (adjusted odds ratio (AOR) 2.23; 95% CI 1.51 to 3.31), injecting with a sex partner (AOR 0.50; 95% CI 0.37 to 0.68), enrollment in addiction treatment (AOR 0.68, 95% CI 0.52 to 0.89) and time since recruitment (AOR 1.29; 95% CI 1.06 to 1.55 per year). Predictors of consistent condom use with casual partners included HIV positivity (AOR 1.70; 95% CI 1.03 to 2.81), syringe borrowing (AOR 0.54; 95% CI 0.32 to 0.91) and syringe lending (AOR 0.52; 95% CI 0.32 to 0.84). CONCLUSIONS Our results demonstrate that among SIF users, consistent condom use was more frequent among casual sex partners and among HIV positive individuals. Importantly, while the prevalence of consistent condom use was low at baseline, it increased over time. Our findings suggest a possible beneficial effect of the SIF on safer sexual practices.
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Affiliation(s)
- B D L Marshall
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, British Columbia, Canada
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15
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Shannon K, Kerr T, Bright V, Gibson K, Tyndall MW. Drug sharing with clients as a risk marker for increased violence and sexual and drug-related harms among survival sex workers. AIDS Care 2008; 20:228-34. [PMID: 18293134 DOI: 10.1080/09540120701561270] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Previous studies have described links between violence, decreased condom use and drug sharing among intimate partners, though limited information exists about the predictors of drug sharing among female sex workers and their clients. The following analysis explored the association between sharing illicit drugs with clients and sexual and drug-related harms among survival sex workers. A total of 198 women participated in interview-administered questionnaires and confidential HIV testing. Of the total, 117 (59%) reported sharing drugs with clients/johns in the last six months and crack cocaine was the primary drug shared (n=108). In logistic regression analysis, sharing drugs with clients/johns was associated with borrowing a used crack pipe (AOR=5.63; 95%CI: 2.71-9.44; p<0.001), intensive/daily crack cocaine smoking (AOR=3.78; 95%CI:1.60-8.92; p<0.002), inconsistent condom use by a client/john (AOR=3.17; 95%CI:1.48-6.77; p<0.003) and having a recent bad date (verbal harassment, physical and/or sexual assault) (AOR=2.71; 95%CI:1.17-6.32; p=0.021). Sharing illicit drugs with clients/johns may be a crucial risk marker for increased violence and sexual and drug-related harms among survival sex workers. HIV prevention and harm reduction initiatives targeting both women and clients/johns are urgently needed, including enhanced support for community and peer-driven sex work initiatives, to address some of the structural facilitators for HIV transmission.
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Affiliation(s)
- K Shannon
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada.
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Berkhout S, Brennan E, Giles S, Joyce B, Smyth S, Tyndall M. “IT’S MORE THAN A PILL DROP”: ADHERENCE SUPPORT AND THE CLINICAL GAZE IN INNER CITY HOME-BASED HIV CARE. CLIN INVEST MED 2008. [DOI: 10.25011/cim.v31i4.4792] [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: 11/03/2022]
Abstract
Background:Home-based HIV care has been identified as means of improving access to HIV care and reducing HIV-related stigma, while easing overload in facility-based care and providing cost effective community-based social supports. Few evaluations, however, focus on the impactof barriers such as homelessness, imprisonment and substance abuse to the continuity of this model of health care provision. This paper examines the challenges, strategies, and outcomes of a long-standing home-based HIV nursingprogram from a Foucauldian analytic perspective.
Methods: Findings are presented from the evaluation of a home care nursing team providing HIV care to unstably housed individuals in Vancouver’s inner city. Employing ethnographic methodology, participant observation was conducted over nine months, along with serial open-ended qualitative interviews with the nursing team (n=4) and home care clients (n=16). Interviews were audio recorded and transcribed; an interpretive thematic analysis of field notes and interview transcripts was conducted.
Results: Although adherence to antiretroviral therapy was consistent over the study course, men and women’s responses to care varied over time. Nurses who were sensitive to the ways in which enhanced surveillance within the private sphere of participants’ lives was cause for resistance to care employed a number of strategies to maintain these relationships. Variability among nurses regarding local (i.e. street) knowledge, along with understandings of what constitutes appropriate supportive measures, also impacted participants’ responses to care.
Conclusions: The type and extent of support services is continually negotiated between nurses and participants, creating a potential source of tension between the guiding of health-related decisions and participants’ constitution of themselves as autonomous. Foucault’s concept of governmentality is applicable here, and may elucidate how norms, capacities and subjectivities are mutually created through its processes. The findings support an understanding of autonomy that is interpersonally, as well as institutionally, relational. Successful programming requires careful attention to the everyday experiences of participants, facilitated by continuity of providers andmentorship for newer nurses engaging in home-based HIV care.
SuzeBerkhout is supported by the Canadian Institutes for Health Research, The Michael Smith Foundation for Health Research, Providence Health, and Vancouver Coastal Health Research Institute.
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Shannon K, Rusch M, Shoveller J, Alexson D, Gibson K, Tyndall MW. Mapping violence and policing as an environmental-structural barrier to health service and syringe availability among substance-using women in street-level sex work. Int J Drug Policy 2008; 19:140-7. [PMID: 18207725 DOI: 10.1016/j.drugpo.2007.11.024] [Citation(s) in RCA: 175] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 11/26/2007] [Accepted: 11/30/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Within street-based sex work and substance-using populations, there is growing evidence to support the role of place, both physical setting and social meanings attached to place, in mediating the effectiveness and reach of health and harm reduction services. METHODS Social mapping was used to explore how health service and syringe availability may be impacted at the geographic level by avoidance of physical settings due to violence and policing among women in street-level sex work. Through a community-based research partnership and extensive peer-led outreach over a 6-month period, women were invited to participate in interview-questionnaires and mapping of their community, working conditions, and access to resources. Results were compiled used ArcGIS software and GIS street maps. In secondary analysis, logistic regression was used to model the geographic association (using likelihood ratio and significance at p<0.05) and stratified models were run to assess differential patterns of avoidance based on age, ethnicity and drug use. RESULTS The findings reveal a significant geographic relationship between a heavily concentrated core area of health and syringe availability and avoidance of physical settings due to violence and policing by 198 women in street-level sex work in Vancouver, Canada. Of particular concern, this correlation is significantly elevated among younger and Aboriginal women, active injection drug users, and daily crack cocaine smokers, suggesting significant environmental-structural barriers to interventions among these vulnerable populations. CONCLUSIONS The resultant displacement of sex work to primarily industrial settings and side streets pushes women further from health and social supports and reduces access to safer injection and drug use paraphernalia. This study offers important evidence for environmental-structural level prevention and safer environment interventions, supported by legal reforms, that facilitate safer sex work environments, including spatial programming, peer-based prevention, outreach and mobile resources, and peer-supervised safer sex work settings.
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Affiliation(s)
- K Shannon
- British Columbia Centre for Excellence in HIV/AIDS, Canada.
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18
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Berkhout SG, Tyndall MW, Anderson S. Through the looking-glass: Objectivity, interpretation, and the construction of social kinds as emerging issues in research ethicss. CLIN INVEST MED 2007. [DOI: 10.25011/cim.v30i4.2842] [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: 11/03/2022]
Abstract
Background: Access to the means of knowledge production is severely limited for many individuals who are socially, politically, and economically disadvantaged. Of particular concern, largely overlooked in bioethics discourse, is the manner by which surveillance, identification, and classification contribute to the creation of particular populations based on harmful social identities, and the subsequent stigmatization of the individuals subject to analysis.
Methods: Drawing from a range of philosophical and sociological literature, including Hans-Georg Gadamer, Charles Taylor, Bruno Latour, and Deborah Lupton, as well as public health discourse, this paper gives an analysis of a challenging metaphysical and ethical problem related to research practices and public health interventions in vulnerable communities. The themes of objectivism and stigmatization are illuminated by focusing on research related to HIV infection among survival sex workers in Vancouver’s downtown eastside.
Results: Reductionist models of human behaviour presuppose a clear distinction between description and evaluation, contributing to an understanding of social reality as structured by objective, base level data, and misconstruing modes of social relations as individual action. In the context of HIV risk, an ethical problem emerges: describing individual actions as “data,” or “fact,” serves to construct and reinforce transgressive social identities. Given that stigmatization is itself part of the context of adverse health outcomes and HIV infection, practices relying on methods that presume representational authority and fail to critically interpret human action are ethically problematic. Resolving difficulties within the methodological underpinnings of public health and HIV behavioural research requires an understanding of many social science methods as hermeneutical, while enabling the contribution of disparate standpoints to the production of scientific knowledge.
Conclusions: The implications of presumed objectivity and representational authority demand a reconsideration of how research in vulnerable communities might be conducted, such that it produces results that are scientifically rigorous and socially responsible.
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Abstract
The objective of this study was to identify psychosocial determinants of, and self-reported reasons for, HAART discontinuation among HIV-positive injection drug users (IDUs). We examined correlates between sociodemographic characteristics, drug use and risk behaviors, outcome expectations, adherence self-efficacy, social support and HAART discontinuation among 160 HIV-positive participants in the Vancouver Injection Drug Users' Study (VIDUS). Logistic regression was used to identify the factors independently associated with discontinuation of HAART. Seventy-one (44%) study participants discontinued HAART during the study period. Factors independently associated with discontinuation of HAART included recent incarceration (OR = 4.84, p = 0.022), negative outcome expectations (OR = 1.41, p = 0.001), adherence efficacy expectations (OR = 0.70, p = 0.003) and self-regulatory efficacy (OR = 0.86, p = 0.050). The most frequently cited reasons provided for discontinuing HAART were being in jail (44%) and medication side effects (41%). The results of this study suggest that psychological constructs derived from self-efficacy theory are highly germane to the understanding of HAART discontinuation behavior and interventions that may change it. Incarceration may result in interruptions in HAART among IDUs, and programmatic changes may be needed to promote optimal retention on HAART among incarcerated HIV-infected IDUs.
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Affiliation(s)
- T Kerr
- Canadian HIV/AIDS Legal Network, St. Paul's Hospital, British Columbia, Canada.
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Berkhout S, Shannon K, Lai C, Kerr T, Tyndall M. Life at the Margins: Understanding the Social Determinants of Hiv/Aids in Women'S Health through Multidisciplinary Translational Research. J Investig Med 2006. [DOI: 10.1177/108155890605401s09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- S.G. Berkhout
- Program, University of British Columbia, Vancouver, BC, Canada
- The Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - K. Shannon
- The Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - C. Lai
- The Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - T. Kerr
- The Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - M. Tyndall
- The Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
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Berkhout SG, Shannon K, Lai C, Kerr T, Tyndall M. 125 LIFE AT THE MARGINS: UNDERSTANDING THE SOCIAL DETERMINANTS OF HIV/AIDS IN WOMEN'S HEALTH THROUGH MULTIDISCIPLINARY TRANSLATIONAL RESEARCH. J Investig Med 2006. [DOI: 10.2310/6650.2005.x0004.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Wood E, Kerr T, Stoltz J, Qui Z, Zhang R, Montaner JSG, Tyndall MW. Prevalence and correlates of hepatitis C infection among users of North America's first medically supervised safer injection facility. Public Health 2005; 119:1111-5. [PMID: 16214189 DOI: 10.1016/j.puhe.2005.05.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Revised: 04/13/2005] [Accepted: 05/23/2005] [Indexed: 12/30/2022]
Abstract
BACKGROUND North America's first medically supervised safer injection facility (SIF) for illicit drug users was opened in Vancouver, Canada on 22 September 2003. We examined the prevalence and correlates of hepatitis C (HCV) infection among a representative cohort of SIF users. METHODS Users of the Vancouver SIF were selected at random and asked to enrol in the Scientific Evaluation of Supervised Injecting (SEOSI) cohort. At baseline, venous blood samples were collected and an interviewer-administered questionnaire was performed. Participants who were HCV-positive were compared with HCV-negative subjects using bivariate and logistic regression analyses. RESULTS Between 1 December 2003 and 30 July 2004, 691 participants were enrolled into the SEOSI cohort, among whom 605 (87.6%) were HCV-positive at baseline. Factors independently associated with HCV infection in logistic regression analyses included: involvement with the sex trade [adjusted odds ratio (AOR) 3.7, 95% confidence interval (CI) 2.1-6.1], history of borrowing syringes (AOR 1.8, 95%CI 1.1-2.9), and history of incarceration (AOR 2.6, 95%CI 1.5-4.4). Daily heroin use was protective against HCV infection (AOR 0.6, 95%CI 0.3-0.9). CONCLUSION The SIF has attracted injection drug users with a high burden of HCV infection and a substantial proportion of uninfected individuals. Although cross-sectional, this study provides some insight into historical risks for HCV infection among this population, and prospective follow-up of this cohort will be useful to determine if use of the SIF is associated with reduced risk behaviour and HCV incidence.
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Affiliation(s)
- E Wood
- Division of Epidemiology and Population Health, British Columbia Center for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, Canada.
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Kerr T, Wood E, Grafstein E, Ishida T, Shannon K, Lai C, Montaner J, Tyndall MW. High rates of primary care and emergency department use among injection drug users in Vancouver. J Public Health (Oxf) 2004; 27:62-6. [PMID: 15564279 DOI: 10.1093/pubmed/fdh189] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.3] [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: 11/12/2022] Open
Abstract
BACKGROUND Frequent use of emergency rooms by injection drug users (IDUs) has been attributed to a lack of access to primary care and barriers to health services. Using a community-based sample of IDUs, we examined rates of primary care and emergency room use among IDUs and identified correlates of frequent emergency department use. METHODS From January to November 2003, we enrolled IDUs into a prospective cohort study involving a baseline questionnaire, comprehensive retrospective and prospective health record linkages. We examined rates of primary care and emergency department utilization, and diagnoses upon arrival in the emergency room. Logistic regression was used to determine factors independently associated with frequent emergency room use. RESULTS Of the 883 IDUs included in this analysis, 687 (78 per cent) accessed a primary care clinic in the previous year, while 528 (60 per cent) participants accessed the emergency room (ER) during the years 2002 and 2003. Abscesses, cellulitis and other skin infections accounted for the greatest proportion of ER use. Factors independently associated with frequent ER use included: frequent crystal methamphetamine injection (AOR = 2.4, 95 per cent CI: 1.0-5.6); non-fatal overdose (AOR = 2.1, 95 per cent CI: 1.4-3.3); HIV-positive status (AOR = 1.5, 95 per cent CI: 1.1-2.1), having been physically assaulted (AOR = 1.5, 95 per cent CI: 1.1-2.1); and primary care utilization (AOR = 1.5, 95 per cent CI: 1.0-2.1). DISCUSSION high rates of ER use were observed among IDUs, despite high rates of primary care use among this same population. ER use was due primarily to preventable injection-related complications that are less amenable to primary care interventions, and therefore educational and prevention efforts that encourage and enable sterile injection practices should be promoted.
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Affiliation(s)
- T Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Canada.
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Spittal PM, Bruneau J, Craib KJP, Miller C, Lamothe F, Weber AE, Li K, Tyndall MW, O'Shaughnessy MV, Schechter MT. Surviving the sex trade: a comparison of HIV risk behaviours among street-involved women in two Canadian cities who inject drugs. AIDS Care 2003; 15:187-95. [PMID: 12856340 DOI: 10.1080/0954012031000068335] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.0] [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: 10/26/2022]
Abstract
In Canada, very little is known about the factors and processes that cause drug-related harm among female intravenous drug users (IDUs). Women who inject drugs and participate in the survival sex trade are considered to be at increased risk for sexual and drug-related harms, including HIV infection. Between September 1999 and September 2000, women participating in the VIDUS cohort in Vancouver and the St. Luc Cohort in Montreal completed interviewer-administered questionnaires. Analyses were conducted to compare the demographic characteristics, sexual risk behaviours, risky injection practices and drug use patterns among women who self-identified as participating in the sex trade with those who did not identify as participating in the sex trade. Logistic regression was used to identify factors independently associated with exchanging sex for money or drugs. HIV prevalence at the study visit (September 1999-2000) was 29% for sex trade workers and 29.2% for non-sex trade workers. While patterns of sexual risk were similar, the risky injection practice and drug use patterns between sex trade workers and non-sex trade workers were markedly different. Logistic regression analysis of cross-sectional data revealed that independent behaviours associated with the sex trade included: greater than once per day use of heroin (adjusted OR 2.7), smokeable crack cocaine (adjusted OR = 3.3) and borrowing used syringes (adjusted OR = 2.0). Creative, client-driven interventions are urgently needed for women who trade sex for money or for drugs.
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Affiliation(s)
- P M Spittal
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6.
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Weber AE, Tyndall MW, Spittal PM, Li K, Coulter S, O'Shaughnessy MV, Schechter MT. High pregnancy rates and reproductive health indicators among female injection-drug users in Vancouver, Canada. EUR J CONTRACEP REPR 2003; 8:52-8. [PMID: 12725675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To determine the incidence of pregnancy among active injection-drug users and to identify factors associated with becoming pregnant. METHODS The Vancouver Injection Drug User Study (VIDUS) is a prospective cohort study that began in 1996. Women who had completed a baseline and at least one follow-up questionnaire between June 1996 and January 2002 were included in the study. Parametric and non-parametric methods were used to compare characteristics of women who reported pregnancy over the study period with those who did not over the same time period. RESULTS A total of 104 women reported a primary pregnancy over the study period. The incidence of pregnancy over the follow-up period was 6.46 (95% confidence interval (CI) 5.24-7.87) per 100 person-years. The average age of women who reported pregnancy was younger than that of women who did not report pregnancy (27 vs. 32 years, p < 0.001). Women of Aboriginal ethnicity were more likely to report pregnancy (odds ratio 1.6, 95% CI 1.0-2.5). Comparison of drug use showed no significant differences in pregnancy rate with respect to the use of heroin, cocaine or crack (p > 0.05). In examining sexual behavior, women who reported having had a regular partner in the previous 6 months were three times more likely to have reported pregnancy. Despite the fact that 67% of women in this study reported using some form of contraception, the use of reliable birth control was low. Only 5% of women in our study reported the use of hormonal contraceptives. CONCLUSION There were a high number of pregnancies among high-risk women in this cohort. This corresponded with very low uptake of reliable contraception. Innovative strategies to provide reproductive health services to at-risk women who are injecting drugs is a public health priority.
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Affiliation(s)
- A E Weber
- Vancouver Injection Drug User Study (VIDUS), BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, Canada
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Tyndall MW, Patrick D, Spittal P, Li K, O'Shaughnessy MV, Schechter MT. Risky sexual behaviours among injection drugs users with high HIV prevalence: implications for STD control. Sex Transm Infect 2002; 78 Suppl 1:i170-5. [PMID: 12083439 PMCID: PMC1765822 DOI: 10.1136/sti.78.suppl_1.i170] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.7] [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: 11/03/2022] Open
Abstract
Injection drug use is inextricably linked to commercial sex work and the transmission of sexually transmitted disease (STD). In many communities prevention efforts have been stalled owing to the marginal existence of this community. This study describes the sexual activities, condom use, reported STDs, and commercial sex work in a large cohort of injection drug users. Seventy two per cent of male and 92% of female subjects in the cohort were sexually active. Among female subjects, 57% reported more than 100 lifetime partners. Condoms were generally not used with regular partners, used about half the time with casual partners, and used about 80% of the time with paying partners. Female sex workers were more likely to have unstable housing and to report incarceration in the previous six months. Reducing the transmission of STDs and HIV in drug using communities is a public health priority. While existing prevention programmes should be strengthened, innovative approaches to STD surveillance, diagnosis, and prevention are needed.
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Affiliation(s)
- M W Tyndall
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, Canada.
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Patrick DM, Rekart ML, Jolly A, Mak S, Tyndall M, Maginley J, Wong E, Wong T, Jones H, Montgomery C, Brunham RC. Heterosexual outbreak of infectious syphilis: epidemiological and ethnographic analysis and implications for control. Sex Transm Infect 2002; 78 Suppl 1:i164-9. [PMID: 12083438 PMCID: PMC1765833 DOI: 10.1136/sti.78.suppl_1.i164] [Citation(s) in RCA: 27] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This study describes the epidemiology and ethnography of an outbreak of infectious syphilis in Vancouver, British Columbia. Between 1996 and 1999, British Columbias's rate of infectious syphilis rose from 0.5 to 3.4 per 100,000, with a dense concentration of cases among sex trade workers, their clients, and street-involved people in the downtown eastside area of Vancouver. Sexual networks were imported cases with secondary spread (dyads and triads), large densely connected dendritic networks of sex trade workers and clients, or occasional starburst networks among gay men. Only 232 of 429 partners were documented as having been treated (54% of those named, or 0.9 per case). The geographical and demographic concentration of this outbreak led to consideration of a programme of focused mass treatment with single dose azithromycin.
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Affiliation(s)
- D M Patrick
- University of British Columbia Centre for Disease Control, Vancouver, Canada.
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Abstract
The prevalence of HIV has been rising among injection drug users (IDUs) and AIDS is now an important cause of death among that population. We tracked mortality and recorded detailed causes of death in the Vancouver Injection Drug Users Study (VIDUS). This is an open cohort of over 1,400 active IDUs that began in May 1996. At enrollment and at semiannual follow-up visits, a trained interviewer administers a detailed semistructured questionnaire. Mortality was recorded during follow-up and detailed causes of death were collected from coroner's reports, hospital records, and the provincial (British Columbia) registry. Causes of death were obtained on 125 participants. Overall, the leading cause of death was overdose accounting for 25% of deaths among HIV-positive participants and 42% among HIV-negative participants. Of the 65 deaths among HIV-positive individuals, 22 (34%) were HIV related. Mortality was associated with older age (adjusted hazards ratio [AHR], 1.03 per year), HIV positivity (AHR, 2.67), injection cocaine use (AHR, 2.23) and methadone treatment (AHR, 0.47). The high rate of HIV in this population has added significantly to the burden of illness and death in this marginalized population.
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Affiliation(s)
- M W Tyndall
- B.C. Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, British Columbia, Canada.
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Patrick DM, Tyndall MW, Cornelisse PG, Li K, Sherlock CH, Rekart ML, Strathdee SA, Currie SL, Schechter MT, O'Shaughnessy MV. Incidence of hepatitis C virus infection among injection drug users during an outbreak of HIV infection. CMAJ 2001; 165:889-95. [PMID: 11599327 PMCID: PMC81496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Beginning in 1994, Vancouver experienced an explosive outbreak of HIV infection among injection drug users (IDUs). The objectives of this study were to measure the prevalence and incidence of hepatitis C virus (HCV) infection in this context and to examine factors associated with HCV seroconversion among IDUs. METHODS IDUs recruited through a study site and street outreach completed interviewer-administered questionnaires covering subjects' characteristics, behaviour, health status and service utilization and underwent serologic testing for HIV and HCV at baseline and semiannually thereafter. A Cox proportional hazards model was used to identify independent correlates of HCV seroconversion. RESULTS As of Nov. 30, 1999, 1345 subjects had been recruited into the study cohort. The prevalence of anti-HCV antibodies was 81.6% (95% confidence interval [CI] 79.6% to 83.6%) at enrollment. Sixty-two HCV seroconversions occurred among 155 IDUs who were initially HCV negative and who returned for follow-up, for an overall incidence density rate of 29.1 per 100 person-years (95% CI 22.3 to 37.3). The HCV incidence remained above 16 per 100 person-years over 3 years of observation (December 1996 to November 1999), whereas HIV incidence declined from more than 19 to less than 5 per 100 person-years. Independent correlates of HCV seroconversion included female sex, cocaine use, injecting at least daily and frequent attendance at a needle exchange program. INTERPRETATION Because of high transmissibility of HCV among those injecting frequently and using cocaine, the harm reduction initiatives deployed in Vancouver during the study period proved insufficient to eliminate hepatitis C transmission in this population.
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Affiliation(s)
- D M Patrick
- University of British Columbia Centre for Disease Control, University of British Columbia, Vancouver, BC.
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Palepu A, Tyndall MW, Leon H, Muller J, O'Shaughnessy MV, Schechter MT, Anis AH. Hospital utilization and costs in a cohort of injection drug users. CMAJ 2001; 165:415-20. [PMID: 11531049 PMCID: PMC81365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Many injection drug users (IDUs) seek care at emergency departments and some require hospital admission because of late presentation in the course of their illness. We determined the predictors of frequent emergency department visits and hospital admissions among community-based IDUs and estimated the incremental hospital utilization costs incurred by IDUs with early HIV infection relative to costs incurred by HIV-negative IDUs. METHODS The Vancouver Injection Drug User Study (VIDUS) is a prospective cohort study involving IDUs that began in 1996. Our analyses were restricted to the 598 participants who gave informed consent for our study. We used the participants' responses to the baseline VIDUS questionnaire and, from medical records at St. Paul's Hospital, Vancouver, we collected detailed information about the frequency of emergency department visits, hospital admissions and the primary diagnosis for all visits or hospital stays between May 1, 1996, and Aug. 31, 1999. The incremental difference in hospital utilization costs by HIV status was estimated, based on 105 admissions in a subgroup of 64 participants. RESULTS A total of 440 (73.6%) of the 598 IDUs made 2763 visits to the emergency department at St. Paul's Hospital during the study period. Of these 440, 265 (160.2%) made frequent visits (3 or more). The following factors were associated with frequent use: HIV-positive status (seroprevalent: adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2-2.6; seroconverted during study period: adjusted OR 3.0, 95% CI 1.6-5.7); more than 4 injections daily (adjusted OR 1.5, 95% CI 1.1-2.1); cocaine use more frequent than use of other drugs (adjusted OR 2.0, 95% CI 1.2-3.6); and unstable housing (adjusted OR 1.5, 95% CI 1.1-2.2). During the study period 210 of the participants were admitted to hospital 495 times; 118 (56.2%) of them were admitted frequently (2 or more admissions). The 2 most common reasons for admission were pneumonia (132 admissions among 79 patients) and soft-tissue infections (cellulitis and skin abscess) (90 admissions among 59 patients). The following factors were independently associated with frequent hospital admissions: HIV-positive status (seroprevalent: adjusted OR 5.4, 95% CI 3.4-8.6; seroconverted during study period: adjusted OR 2.9, 95% CI 1.4-6.0); and female sex (adjusted OR 1.8, 95% CI 1.1-3.1). The incremental hospital utilization costs incurred by HIV-positive IDUs relative to the costs incurred by HIV-negative IDUs were $1752 per year. INTERPRETATION Hospital utilization was significantly higher among community-based IDUs with early HIV disease than among those who were HIV negative. Much of the hospital use was related to complications of injection drug use and may be reduced with the establishment of programs that integrate harm reduction strategies with primary care and addiction treatment.
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Affiliation(s)
- A Palepu
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Department of Medicine, University of British Columbia, Vancouver.
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Wood E, Tyndall MW, Spittal PM, Li K, Kerr T, Hogg RS, Montaner JS, O'Shaughnessy MV, Schechter MT. Unsafe injection practices in a cohort of injection drug users in Vancouver: could safer injecting rooms help? CMAJ 2001; 165:405-10. [PMID: 11531048 PMCID: PMC81364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND In several European countries safer injecting rooms have reduced the public disorder and health-related problems of injection drug use. We explored factors associated with needle-sharing practices that could potentially be alleviated by the availability of safer injecting rooms in Canada. METHODS The Vancouver Injection Drug User Study is a prospective cohort study of injection drug users (IDUs) that began in 1996. The analyses reported here were restricted to the 776 participants who reported actively injecting drugs in the 6 months before the most recent follow-up visit, during the period January 1999 to October 2000. Needle sharing was defined as either borrowing or lending a used needle in the 6-month period before the interview. RESULTS Overall, 214 (27.6%) of the participants reported sharing needles during the 6 months before follow-up; 106 (13.7%) injected drugs in public, and 581 (74.9%) reported injecting alone at least once. Variables independently associated with needle sharing in a multivariate analysis included difficulty getting sterile needles (adjusted odds ratio [OR] 2.7, 95% confidence interval [CI] 1.8-4.1), requiring help to inject drugs (adjusted OR 2.0, 95% CI 1.4-2.8), needle reuse (adjusted OR 1.8, 95% CI 1.3-2.6), frequent cocaine injection (adjusted OR 1.6, 95% CI 1.1-2.3) and frequent heroin injection (adjusted OR 1.5, 95% CI 1.04-2.1). Conversely, HIV-positive participants were less likely to share needles (adjusted OR 0.5, 95% CI 0.4-0.8), although 20.2% of the HIV-positive IDUs still reported sharing needles. INTERPRETATION Despite the availability of a large needle-exchange program and targeted law enforcement efforts in Vancouver, needle sharing remains an alarmingly common practice in our cohort. We identified a number of risk behaviours--difficulty getting sterile needles, needle sharing and reuse, injection of drugs in public and injecting alone (one of the main contributing causes of overdose)--that may be alleviated by the establishment of supervised safer injecting rooms.
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Affiliation(s)
- E Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Department of Health Care and Epidemiology, University of British Columbia, Vancouver
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Wood E, Chan K, Montaner JS, Schechter MT, Tyndall M, O'Shaughnessy MV, Hogg RS. The end of the line: has rapid transit contributed to the spatial diffusion of HIV in one of Canada's largest metropolitan areas? Soc Sci Med 2000; 51:741-8. [PMID: 10975233 DOI: 10.1016/s0277-9536(99)00479-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of this study is to describe the relationship between socio-demographic characteristics and the geographic distribution of persons with HIV in the metropolitan area surrounding Vancouver, British Columbia. Specifically, we sought to determine the location of persons with HIV and the population based characteristics related to the rate of anti-HIV medication use. In addition, we investigated the relationship between the distribution of persons on anti-HIV medications and the city's monorail "SkyTrain" route. The residences of persons on anti-HIV therapy were linked to Census Tracts. Data from the most recent census were used to create a socio-demographic profile of each geographic area. The spatial relationship between the distribution of persons on anti-HIV therapy and the path of the monorail was assessed by digitizing the SkyTrain route over a digital Census Tract map. Statistical analyses were used to determine the characteristics of Census Tracts associated with the rate of anti-HIV medication use. The overall rate of anti-HIV medication use in the Census Tracts that are within 1 km of SkyTrain was 66 per 100,000 population, whereas the rate was only 22 in the non-proximal Census Tracts. Multivariate analyses indicated that persons on anti-HIV therapy were significantly less likely to reside where there is a higher proportion of the population female, and were more likely to reside in areas with a higher proportion of the population of First Nations or Aboriginal descent, a higher population density, and in areas within 1 km of the SkyTrain route. Our analyses suggest that neither migration, nor a heightened access to therapy explain these findings. The environment surrounding the SkyTrain may have been conducive to the spatial diffusion of HIV, and could be the focus of targeted public health interventions. The mechanisms responsible for the clustering of persons on anti-HIV medications around the SkyTrain require further investigation.
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Affiliation(s)
- E Wood
- British Columbia Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada
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Wood E, Braitstein P, Montaner JS, Schechter MT, Tyndall MW, O'Shaughnessy MV, Hogg RS. Extent to which low-level use of antiretroviral treatment could curb the AIDS epidemic in sub-Saharan Africa. Lancet 2000; 355:2095-100. [PMID: 10902622 DOI: 10.1016/s0140-6736(00)02375-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Despite growing international pressure to provide HIV-1 treatment to less-developed countries, potential demographic and epidemiological impacts have yet to be characterised. We modelled the future impact of antiretroviral use in South Africa from 2000 to 2005. METHODS We produced a population projection model that assumed zero antiretroviral use to estimate the future demographic impacts of the HIV-1 epidemic. We also constructed four antiretroviral-adjusted scenarios to estimate the potential effect of antiretroviral use. We modelled total drug cost, cost per life-year gained, and the proportion of per-person health-care expenditure required to finance antiretroviral treatment in each scenario. FINDINGS With no antiretroviral use between 2000 and 2005, there will be about 276,000 cumulative HIV-1-positive births, 2,302,000 cumulative new AIDS cases, and the life expectancy at birth will be 46.6 years by 2005. By contrast, 110,000 HIV-1-positive births could be prevented by short-course antiretroviral prophylaxis, as well as a decline of up to 1 year of life expectancy. The direct drug costs of universal coverage for this intervention would be US$54 million--less than 0.001% of the per-person health-care expenditure. In comparison, triple-combination treatment for 25% of the HIV-1-positive population could prevent a 3.1-year decline in life expectancy and more than 430,000 incident AIDS cases. The drug costs of this intervention would, however, be more than $19 billion at present prices, and would require 12.5% of the country's per-person health-care expenditure. INTERPRETATION Although there are barriers to widespread HIV-1 treatment, limited use of antiretrovirals could have an immediate and substantial impact on South Africa's AIDS epidemic.
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Affiliation(s)
- E Wood
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, Canada
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Abstract
OBJECTIVE To model the potential impact of HIV infection rates and the use of antiretroviral medication on life expectancy and mortality in the Downtown Eastside of Vancouver, British Columbia, Canada, from 1999 to 2006. DESIGN Population projections were made to estimate the population of the Downtown Eastside in the year 2006. METHODS Two scenarios were modelled to predict the impact of HIV infection and antiretroviral use on mortality and life expectancy. The use of antiretroviral therapy was estimated to be 80% in the first scenario and 20% in the second. The prevalence of HIV by age and sex, and by year infected was estimated using data from the Vancouver Injection Drug User Study. RESULTS If the level of antiretroviral therapy use among HIV-positive individuals was 80% at baseline, then we estimate that the life expectancy at birth in the year 2006 will be 60.8 years for men and 72.8 years for women, and 172 AIDS deaths will occur between 1999 and 2006. In contrast, if the present level of antiretroviral medication use persists, the life expectancy at birth in the year 2006 will be 56.9 years for men and 68.6 years for women, and 503 AIDS deaths will occur between 1999 and 2006. CONCLUSION Our analysis suggests that if the low levels of antiretroviral therapy use persist, life expectancy in Vancouver's Downtown Eastside will soon be on a par with many of the world's least developed countries. Our findings highlight the large health status decline that can be expected in many inner city neighbourhoods if low levels of antiretroviral use persist. Although reasonable coverage targets for injection drug users (IDU) have not been established, the expanded use of antiretroviral medication is urgently needed to avert a drastic decline in health status.
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Affiliation(s)
- E Wood
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, Canada
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Tyndall MW, Schechter MT. HIV testing of patients: let's waive the waiver. CMAJ 2000; 162:210-1. [PMID: 10674056 PMCID: PMC1232273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Affiliation(s)
- M W Tyndall
- Department of Health Care and Epidemiology, Faculty of Medicine, University of British Columbia, Vancouver.
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Malonza IM, Tyndall MW, Ndinya-Achola JO, Maclean I, Omar S, MacDonald KS, Perriens J, Orle K, Plummer FA, Ronald AR, Moses S. A randomized, double-blind, placebo-controlled trial of single-dose ciprofloxacin versus erythromycin for the treatment of chancroid in Nairobi, Kenya. J Infect Dis 1999; 180:1886-93. [PMID: 10558945 DOI: 10.1086/315133] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [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: 11/03/2022] Open
Abstract
A randomized, double-blind, placebo-controlled clinical trial was conducted in Nairobi, Kenya, to compare single-dose ciprofloxacin with a 7-day course of erythromycin for the treatment of chancroid. In all, 208 men and 37 women presenting with genital ulcers clinically compatible with chancroid were enrolled. Ulcer etiology was determined using culture techniques for chancroid, serology for syphilis, and a multiplex polymerase chain reaction for chancroid, syphilis, and herpes simplex virus (HSV). Ulcer etiology was 31% unmixed chancroid, 23% unmixed syphilis, 16% unmixed HSV, 15% mixed etiology, and 15% unknown. For 111 participants with chancroid, cure rates were 92% with ciprofloxacin and 91% with erythromycin. For all study participants, the treatment failure rate was 15%, mostly related to ulcer etiologies of HSV infection or syphilis, and treatment failure was 3 times more frequent in human immunodeficiency virus-infected subjects than in others, mostly owing to HSV infection. Ciprofloxacin is an effective single-dose treatment for chancroid, but current recommendations for empiric therapy of genital ulcers may result in high treatment failure due to HSV infection.
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Affiliation(s)
- I M Malonza
- Department of Medical Microbiology, University of Nairobi, Nairobi City Commission, Nairobi, Kenya
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Tyndall MW, Kidula N, Sande J, Ombette J, Temmerman M. Predicting Neisseria gonorrhoeae and Chlamydia trachomatis infection using risk scores, physical examination, microscopy, and leukocyte esterase urine dipsticks among asymptomatic women attending a family planning clinic in Kenya. Sex Transm Dis 1999; 26:476-82. [PMID: 10494940 DOI: 10.1097/00007435-199909000-00010] [Citation(s) in RCA: 19] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sexually transmitted infections (STIs) continue to exert a tremendous health burden on women in developing countries. Poor socioeconomic status, inadequate knowledge, lack of diagnostic facilities, and shortages of effective treatment all contribute to the high incidence of STIs. The use of clinical algorithms for the detection and management of STIs has gained widespread acceptance in settings where there are limited resources. Evaluation of these algorithms have been few, especially in women who are not recognized as members of high-risk groups. OBJECTIVES To develop a simple scoring system based on historical and demographic data, physical findings, microscopy, and leukocyte esterase (LE) urine dipsticks to predict cervical gonococcal and chlamydial infection among asymptomatic women. METHODS One thousand and forty-eight women attending an urban family planning clinic in Nairobi were randomly selected to participate. After the identification of factors that were associated with infection, we assigned one point each for: age 25 or younger, single status, two or more sex partners in the past year, cervical discharge, cervical swab leukocytes, and a positive LE urine dipstick. Identification of any one of these six factors gave a sensitivity of 85% and a specificity of 30% for the detection of cervical infections. A positive LE urine dipstick had a sensitivity of 63 % and a specificity of 47% when used alone and did not contribute to the identification of infection if a physical examination was performed. The application of existing clinical algorithms to this population performed poorly. CONCLUSIONS The use of risk scores, physical examination, microscopy, and the urine LE dipstick, used alone or in combination, as predictors of gonococcal or chlamydial cervical infection was of limited utility in low-risk, asymptomatic women. Accurate diagnostic testing is necessary to optimize treatment.
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Affiliation(s)
- M W Tyndall
- Department of Health Care and Epidemiology, University of British Columbia, Vancouver, Canada
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Temmerman M, Tyndall MW, Kidula N, Claeys P, Muchiri L, Quint W. Risk factors for human papillomavirus and cervical precancerous lesions, and the role of concurrent HIV-1 infection. Int J Gynaecol Obstet 1999; 65:171-81. [PMID: 10405062 DOI: 10.1016/s0020-7292(99)00043-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To identify risk factors for human papillomavirus (HPV) infection and squamous intraepithelial lesions (SIL) of the cervix, and to measure the impact of concurrent HIV-1 infection. METHODS Women were studied at a family planning clinic in Nairobi, Kenya. Demographic and historical information was obtained using a semi-structured questionnaire and specimens were collected for sexually transmitted diseases (STDs), HPV, cervical cytology, and HIV-1 testing. RESULTS HPV was detected in 87 of 513 women (17%), including 81 (93%) oncogenic types (16, 18, 31, 33 and others) and six (7%) non-oncogenic types (6 and 11). HIV-1 prevalence was 10%. HPV detection was associated with HIV-1 infection [adjusted odds ratio (aOR) 3.9, 95% confidence interval (CI), 2.0-7.7], sexual behavior indicators including the number of sex partners and inflammatory STDs, as well as the number of pregnancies (0 or 1 vs. > or = 3, aOR 0.4; 95% CI, 0.2-0.9). SIL was detected in 61 women (11.9%), including 28 (46%) with low-grade lesions (LSIL) and 33 (54%) with high-grade lesions (HSIL). HPV infection was strongly associated with HSIL (OR 14.9; 95% CI, 6.8-32.8). In a multivariate model predictors of HSIL included HIV-1 serpositivity (aOR 4.8; 95% CI, 1.8-12.4), the number of lifetime sex partners (0-1 vs. > or = 4; aOR 3.8; 95% CI, 1.1-13.5), and older age (< 26 vs. > 30; OR 3.9; 95% CI, 1.1-13.6). An analysis stratified by HIV-1 showed a stronger association between HPV and HSIL in HIV-1 negative women (OR 17.0; 95% CI, 6.4-46.3) then in HIV-1 positive women (OR 4.5; 95% CI, 0.8-27.4). CONCLUSION Our results indicate that HSIL and even invasive cancer are highly prevalent in this setting of women on reproductive age considered to be at low risk for STDs, suggesting that routine Pap smear screening may save lives.
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Affiliation(s)
- M Temmerman
- International Centre for Reproductive Health, University of Ghent, Belgium.
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Claeys G, Taelman H, Gichangi P, Tyndall M, Ombete J, Verschraegen G, Temmeperman M. Antimicrobial susceptibility of Neisseria gonorrhoeae isolates from men with urethritis in Kenya. Br J Vener Dis 1998. [DOI: 10.1136/sti.74.4.294-a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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40
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Claeys G, Taelman H, Gichangi P, Tyndall M, Ombete J, Verschraegen G, Temmeperman M. Antimicrobial susceptibility of Neisseria gonorrhoeae isolates from men with urethritis in Kenya. Sex Transm Infect 1998; 74:294-5. [PMID: 9924474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Affiliation(s)
- G Claeys
- Department of Medical Microbiology, University Hospital, Gent, Belgium
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Temmerman M, Kidula N, Tyndall M, Rukaria-Kaumbutho R, Muchiri L, Ndinya-Achola JO. The supermarket for women's reproductive health: the burden of genital infections in a family planning clinic in Nairobi, Kenya. Sex Transm Infect 1998; 74:202-4. [PMID: 9849556 PMCID: PMC1758107 DOI: 10.1136/sti.74.3.202] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [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: 11/03/2022] Open
Abstract
OBJECTIVES To study the burden of disease of reproductive tract infections (RTIs) and cervical dysplasia in women attending a family planning clinic in Nairobi, Kenya, and to assess the acceptability of integrating reproductive healthcare services into existing family planning facilities. METHODS In a family planning clinic in Nairobi, Kenya, 520 women were enrolled in a study on RTI and cervical dysplasia. RESULTS RTI pathogens were detected in over 20% of women, the majority being asymptomatic. HIV-1 testing was positive in 10.2%. The diagnosis of cervical dysplasia was made on 12% of the cytology smears (mild in 5.8%, moderate in 3.5%, severe in 1.2%), and 1.5% had invasive cervical cancer. The intervention of case detection of RTI and Papanicolaou smear taking was well received by clients and considered feasible by the staff. CONCLUSIONS Early detection and treatment of potentially curable cervical lesions and RTI provide a unique opportunity to improve women's health. In Kenya, where the current contraceptive prevalence rate is 33%, family planning clinics are excellent sites to introduce health interventions.
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Affiliation(s)
- M Temmerman
- Department Obstetrics and Gynaecology, University of Ghent, Belgium
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Tyndall MW, Ronald AR, Agoki E, Malisa W, Bwayo JJ, Ndinya-Achola JO, Moses S, Plummer FA. Increased risk of infection with human immunodeficiency virus type 1 among uncircumcised men presenting with genital ulcer disease in Kenya. Clin Infect Dis 1996; 23:449-53. [PMID: 8879763 DOI: 10.1093/clinids/23.3.449] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.4] [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: 02/02/2023] Open
Abstract
The factors responsible for the explosive spread of human immunodeficiency virus type 1 (HIV-1) in sub-Saharan Africa continue to be identified and debated. One of the most controversial factors has been male circumcision. This cross-sectional study was conducted to measure the association between circumcision status and infection with HIV-1 among men with genital ulcer disease. Eight hundred and ten men participated in the study, of whom 190 (23%) were HIV-1-positive. A logistic regression model adjusted for behavioral and historical showed that HIV-1 positivity was independently associated with being uncircumcised (adjusted odds ratio [OR], 4.8; 95% confidence interval [CI], 3.3-7.2) and with a history of urethral discharge (adjusted OR, 2.0; 95% CI, 1.4-2.8). This association could not be explained by measures of sexual exposure to HIV-1 among this population. Male circumcision should be considered as an intervention strategy for AIDS control.
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Affiliation(s)
- M W Tyndall
- Department of Medical Microbiology, University of Nairobi, Kenya
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Turley K, Tyndall M, Turley KM, Roge C, Cooper M, Tarnoff H. Cardiovascular-radical outcome method is effective in complex congenital cardiac lesions. Ann Thorac Surg 1996; 62:386-91; discussion 391-2. [PMID: 8694596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The cardiovascular-radical outcome method is a proactive process of patient care that uses standard critical pathway methodology to reduce negative variation while encouraging positive variation to accelerate recovery. Its effectiveness in patients with complex congenital heart disease is explored. METHODS Two hundred fourteen consecutive patients with congenital heart disease were cared for using the cardiovascular radical outcome method. Age ranged from 2 days to 19 years (median age, 3 years). Cardiovascular radical outcome method data were compared with the pathway plan data for each patient. RESULTS Survival was 99% (211 patients) with an overall reduction in stay of 156 days (0.74 day/patient) (p < 0.0001). Only 10 patients (5%) exceeded the pathway plan; 201 (95%) reached the planned length of stay (critical pathway method), and 127 patients (60%) had a shorter length of stay than expected by the critical pathway method. One hundred forty-eight patients (70%), including 95 (64%) with more complex conditions, had a length of stay of 3 days and 18% achieved a 2-day length of stay, the maximal response. The process was most effective in the most complex groups, although preoperative comorbidities influenced outcomes. Outcome assessment demonstrated minimal morbidity and excellent family satisfaction. CONCLUSIONS The radical outcome method is effective in reducing the length of stay of patients with complex congenital heart disease. The power is in the process rather than the plan, and the method provides optimal patient care and family satisfaction.
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Affiliation(s)
- K Turley
- California Pacific Medical Center, San Francisco 94115, USA
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Mahony JB, Luinstra KE, Tyndall M, Sellors JW, Krepel J, Chernesky M. Multiplex PCR for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in Genitourinary specimens. J Clin Microbiol 1995; 33:3049-53. [PMID: 8576375 PMCID: PMC228636 DOI: 10.1128/jcm.33.11.3049-3053.1995] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
We developed a multiplex PCR (M-PCR) assay for the simultaneous detection of Chlamydia trachomatis and Neisseria gonorrhoeae. M-PCR employed C. trachomatis-specific primers KL1-KL2 and N. gonorrhoeae-specific primers HO1-HO3 and produced products of 241 and 390 bp, respectively. PCR products were easily detected by agarose gel electrophoresis and confirmed by Southern hybridization using labelled oligonucleotide probes. M-PCR had a sensitivity of 10 fg of C. trachomatis and N. gonorrhoeae DNA (equivalent to 1 to 2 genome copies). M-PCR detected the presence of C. trachomatis and N. gonorrhoeae DNA in 15 male urethral and 12 female endocervical specimens, 3 of which were positive for C. trachomatis, 18 of which were positive for N. gonorrhoeae and 6 of which were positive for both organisms. M-PCR was evaluated further by testing 200 male first void urine (FVU) specimens, of which 18 were positive by C. trachomatis PCR and Chlamydiazyme and 4 were positive by C. trachomatis PCR but negative by Chlamydiazyme. All 22 FVU specimens were positive by a confirmatory PCR using a second plasmid target and were positive by M-PCR. Ten of 11 men with cultures that were positive for N. gonorrhoeae had FVU specimens that were positive by both N. gonorrhoeae PCR and M-PCR. Two other men with negative N. gonorrhoeae urethral cultures had FVU specimens that were positive by N. gonorrhoeae PCR, by two confirmatory N. gonorrhoeae PCR assays using 165 rRNA and cytosine methyltransferase primers, and by M-PCR. The sensitivity of M-PCR for detecting C. trachomatis was 100% (22 of 22 specimens), compared with 81.8% (18 of 22 specimens) for enzyme immunoassay. Sensitivity of M-PCR for N. gonorrhoeae was 92.3% (12 of 13 specimens) compared with 84.6% (11 of 13 specimens) for urethral culture. The specificity of M-PCR was 100% for both C. trachomatis (178 of 13 specimens) and N. gonorrhoeae (187 of 187 specimens). M-PCR testing of FVU specimens provided a sensitive and noninvasive method for detecting C. trachomatis and N. gonorrhoeae infection in men.
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Affiliation(s)
- J B Mahony
- Regional Virology and Chlamydiology Laboratory, McMaster University, Hamilton, Canada
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Abstract
BACKGROUND Treatment of congenital heart disease has entered a new era of healthcare delivery and cost containment. Critical pathway method (CPM) has been previously demonstrated by us to produce a significant reduction in average length of stay (ALOS) in hospital of -44%. A new approach, radical outcome method (ROM), has produced comparable results that appear to improve over time. The dynamic nature is examined. METHODS AND RESULTS Two hundred consecutive patients with congenital heart disease were treated by a single surgeon at a single health maintenance organization (HMO) facility. ROM was used in all patients. This method uses seven critical moments at which shortening rather than confirmation of the ALOS is possible. This process is completed by the second post-operative day. Overall mortality was 1%. The 200 patients were divided into two consecutive groups of 100 patients to determine the effectiveness of ROM over time. Fifty sets were matched. ALOS hospital decreased by 29 days (mean, 0.6 d/set), P < .003. Thirty sets who underwent cardiopulmonary bypass had a 16% decrease (P < .03), and 20 sets in whom nonbypass procedures were performed had a decrease of 16% (P < .02). ALOS in hospital for the 50 sets decreased from 3.7 to 3.1 days (-16%, P < .003). Outcome data demonstrated no significant difference. CONCLUSIONS ROM, a proactive approach to hospital stay, is a dynamic process that reduces ALOS in hospital. This is achieved by both reducing negative variation in the standard CPM and allowing for positive variation. Outcome data confirm that this approach can reduce ALOS in hospital while providing optimal patient care and family satisfaction, a standard for the new era of healthcare delivery.
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Affiliation(s)
- K Turley
- Department of Cardiovascular Surgery, California Pacific Medical Center, San Francisco 94115, USA
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Tyndall MW, Nasio J, Agoki E, Malisa W, Ronald AR, Ndinya-Achola JO, Plummer FA. Herpes zoster as the initial presentation of human immunodeficiency virus type 1 infection in Kenya. Clin Infect Dis 1995; 21:1035-7. [PMID: 8645797 DOI: 10.1093/clinids/21.4.1035] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [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: 02/01/2023] Open
Abstract
We conducted a prospective observational study to determine the clinical features, the degree of immunosuppression, and the prevalence of human immunodeficiency virus type 1 (HIV-1) infection associated with herpes zoster in Kenya. The study included 196 HIV-1 positive individuals and 34 HIV-1 negative individuals between the ages of 16 and 50 years who presented to a referral clinic in Nairobi. Comparison of the clinical characteristics in the two groups found that the duration of illness in the HIV-1-positive group was longer (32 vs. 22 days; P < .001) and that the HIV-1-positive group was more likely to have generalized lymphadenopathy (74% vs. 3%; OR: 12.2; 95% CI: 1.6, 91.7), severe pain (69% vs. 39%; OR: 3.6; 95% CI; 1.7, 7.6), bacterial superinfection (15% vs. 6%; OR: 5.7; 95% CI: 1.3, 25.0), and more than one affected dermatome (38% vs. 18%; OR: 2.8; 95% CI: 1.1, 8.0). Dermatomal distribution of the lesions was similar in the two groups, except for cranial lesions, which occurred exclusively in the HIV-1-positive group. The mean CD4 T lymphocyte count at presentation was 333/mm(3) in the HIV-1-positive group and 777/mm(3) in the HIV-1-negative group (P < .001). Herpes zoster is often recognized as the initial HIV-1-related illness in Kenya despite the fact that patients have moderate to severe depression of CD4 cell counts at presentation. Although the clinical features of herpes zoster may be more severe in HIV-1-positive individuals, recovery is generally complete and uncomplicated.
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Affiliation(s)
- M W Tyndall
- World Health Organization Collaborating Centre for Research and Training in Sexually Transmitted Diseases, Nairobi, Kenya
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Tyndall MW, Gomez AM, Maitha G, Ndinya-Achola JO, MacLean I, Plummer FA, Rosenthal KL. Early detection of HIV-1 in men from Kenya using a synthetic peptide and a p24 antigen enzyme-linked immunosorbent assay. AIDS 1994; 8:1625-6. [PMID: 7848603 DOI: 10.1097/00002030-199411000-00019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Tyndall MW, Agoki E, Malisa W, Ndinya-Achola JO, Ronald AR, Plummer FA. Sexual behavior and perceived risk of AIDS among men in Kenya attending a clinic for sexually transmitted diseases. Clin Infect Dis 1994; 19:441-7. [PMID: 7811863 DOI: 10.1093/clinids/19.3.441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [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: 01/27/2023] Open
Abstract
The sexual transmission of human immunodeficiency virus type 1 (HIV-1) continues at an alarming rate in sub-Saharan Africa despite the fact that awareness of AIDS is high. One explanation for this alarming rate may be that individuals do not believe that they are personally at risk for AIDS and are not sufficiently motivated to make changes in their behavior. We conducted a cross-sectional study of men with genital ulcer disease to assess their sexual behavior and their perceived risk of AIDS. We studied 787 men between the ages of 17 and 54 years who presented to a referral clinic for sexually transmitted diseases (STDs) in Nairobi, Kenya. Of these 787 men, 188 (24%) were infected with HIV-1. Awareness of AIDS was essentially universal in this population; however, only 64 men (8%) thought that they were personally at risk of developing AIDS. A logistic regression analysis found that men who believed they were personally at risk knew someone with AIDS (odds ratio [OR], 8.9; 95% confidence interval [CI], 4.0-19.7), received information about AIDS from television or video (OR, 3.0; 95% CI, 1.7-5.5), or had previously had an STD (OR, 2.2; 95% CI, 1.2-4.1). Except for a modest increase in condom use, there was no significant difference in sexual behavior between the group who considered themselves to be at risk for AIDS and the group who did not consider themselves to be at risk. The results of this study challenge the current strategies on HIV/AIDS education and prevention for urban men in Kenya.
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Affiliation(s)
- M W Tyndall
- Department of Medical Microbiology, University of Nairobi, Kenya
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Plourde PJ, Pepin J, Agoki E, Ronald AR, Ombette J, Tyndall M, Cheang M, Ndinya-Achola JO, D'Costa LJ, Plummer FA. Human immunodeficiency virus type 1 seroconversion in women with genital ulcers. J Infect Dis 1994; 170:313-7. [PMID: 8035016 DOI: 10.1093/infdis/170.2.313] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.2] [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: 01/28/2023] Open
Abstract
Genital ulcers are implicated as a risk factor enhancing susceptibility to human immunodeficiency virus type 1 (HIV-1) infection. A prospective study to determine the incidence of and risk factors associated with acquisition of HIV-1 in women with genital ulcers was done. HIV-1-seronegative women with genital ulcers attending a clinic for sexually transmitted diseases in Nairobi were followed to HIV-1 seroconversion over a 6-month period. Of 81 women, 10 seroconverted to HIV-1. The crude 6-month incidence of HIV-1 infection was 12%. Risk factors associated with seroconversion included cervical ectopy (rate ratio [RR], 4.9; 95% confidence interval [CI], 1.5-15.6) and pelvic inflammatory disease (RR, 6.3; 95% CI, 1.9-20.4). Thus, cervical ectopy and pelvic inflammatory disease may increase susceptibility to HIV-1 in women with genital ulcers.
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Affiliation(s)
- P J Plourde
- Department of Medical Microbiology, University of Nairobi, Kenya
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Abstract
Critical pathway methodology has been demonstrated to provide producible reduction in average length of stay (ALOS) in adults in certain diagnostic-related groups and operations such as coronary artery bypass grafting. The efficacy of this approach in congenital heart surgery was explored. Two hundred eighty-six consecutive patients from a health maintenance organization treated by a single surgeon since the institution of diagnostic-related group coding at that health maintenance organization constituted the study group. One hundred fourteen patients were treated at a university hospital without critical pathway methodology (group 1) and 172, subsequently at the health maintenance organization institution using the methodology (group 2). Operation/lesion, age, and diagnostic-related group matching was possible in 61 pairs. Examination of the ALOS Hospital (operative and postoperative days) for the entire cohort revealed a 43.8% reduction in ALOS Hospital (p < 0.0001) and a 39.0% reduction in ALOS Intensive Care Unit (p < 0.0001). There was also significant reduction in ALOS Hospital and ALOS Intensive Care Unit in the operation/lesion-matched subsets. Outcome measures including operative and late mortality, readmission, unscheduled emergency room and clinic visits, and health maintenance organization family assessment survey demonstrated no improvement in outcome with increased hospital stay. Thus, critical pathway methodology when used in patients undergoing a congenital heart operation produces a significant reduction in hospital stay and intensive care unit stay as well as quality patient care with uniformity of outcome.
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Affiliation(s)
- K Turley
- California Pacific Medical Center, San Francisco 94115
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