Sexually transmitted and blood-borne infection risk reduction with methadone and buprenorphine/naloxone among people with prescription-type opioid use disorder: Findings from a Canadian pragmatic randomized trial.

INTRODUCTION: People who use drugs are disproportionally affected by sexually transmitted and blood-borne infections (STBBIs). While the benefits of methadone in reducing injecting-risk behaviours are well documented, less is known on its impacts on sexual-related risks, as well as its comparative effectiveness to buprenorphine/naloxone, particularly in the context of highly potent opioids. The aim of this study was to estimate the relative effects of buprenorphine/naloxone and methadone on injecting and STBBI risks among people with prescription-type opioid use disorder (POUD). METHODS: Secondary analysis of a pan-Canadian pragmatic 24-week randomized clinical trial comparing methadone and buprenorphine/naloxone models of care among 272 people with POUD (including licit or illicit opioid analgesics, fentanyl). The Risk Behaviour Survey was used to collect injecting and sexual risks at baseline, and weeks 12 and 24. RESULTS: In total, 210 participants initiated treatment (103 buprenorphine/naloxone and 107 methadone). At baseline, 113/205 (55.1%) participants reported recently injecting drugs, 37/209 (17.7%) unsafe injection practices and 67/162 (41.4%) high-risk sex. Both methadone and buprenorphine/naloxone were associated with reductions in the prevalence of injection drug use and high-risk sex at weeks 12 and 24 with no interactions between treatment arm and time. CONCLUSION: Methadone and buprenorphine/naloxone were similarly effective in reducing injecting and sexual risk behaviours among people with POUD. CLINICAL TRIALS REGISTRATION: clinicaltrials.gov NCT03033732.

Perspectives on digital testing services for sexually transmitted and blood-borne infections from Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour living in Ontario, Canada.

OBJECTIVES: Increased sexually transmitted and blood-borne infections (STBBI) testing can reduce the burden of disease among Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour (2SGBTQ+ BIPOC). However, this population encounters barriers, such as discrimination, when accessing in-person STBBI testing services. Digital STBBI testing, such as self-testing/collection kits ordered online and digital requisitions, may address some of these barriers. Our aim was to understand acceptability of free digital STBBI testing among 2SGBTQ+ BIPOC living in Ontario, Canada. DESIGN: We approached this analysis using Implementation Science and Critical Race Theory. We conducted interviews and focus groups with 21 2SGBTQ + BIPOC individuals from 2020-2021. Participants were asked about their perceptions of the benefits and drawbacks of digital STBBI testing, populations that would benefit from using these services, and recommendations for how these services may be implemented in Ontario. Interviews and focus groups were transcribed verbatim and analyzed using reflexive thematic analysis. RESULTS: Six themes emerged. Digital STBBI testing services: (1) May reduce oppression experienced by 2SGBTQ + BIPOC when testing in-person; (2) Should address the unique needs that 2SGBTQ + BIPOC experience due to other intersecting identities they possess; (3) Should adapt their services to suit the varying cultural contexts and living circumstances of 2SGBTQ + BIPOC; (4) Should be accessible to 2SGBTQ + BIPOC who hold diverse or no documentation; (5) Should be offered in multiple languages; (6) May be inaccessible to those without Internet access or devices. CONCLUSION: Digital STBBI testing is one strategy that may reduce discrimination experienced by 2SGBTQ + BIPOC when getting tested in-person. However, digital STBBI testing services may not address all the needs of 2SGBTQ + BIPOC. Racism and other forms of oppression embedded into in-person and digital testing services will need to be addressed to meet the needs of this diverse population.

Patterns of Event-Level Concurrent Substance Use During Sex Among Gay, Bisexual, and Other Men Who Have Sex with Men in Metro Vancouver.

This study identified patterns of sexualized substance use among gay, bisexual, and other men who have sex with men (gbMSM) and examined associated risk factors for sexually transmitted and blood borne infections (STBBI). Data were from a longitudinal cohort recruited using respondent-driven sampling between Feb-2017 and Feb-2019. Participants reported on events with up to five of their most recent sexual partners. Latent class analysis examined patterns of concurrent substance use 2 h prior to or during sex. Multinomial regression identified demographic, partner-level, and event-level factors associated across 11,877 sexual events reported by 757 participants. Most combinations of substance use were rare, but most drugs were frequently combined with other drugs when they were used prior to or during a sexual event. Six latent classes of concurrent event-level substance use were identified. The referent class (58.8% of events) was characterized by limited use of any drugs. The Common Drug Use class (12.1%) was characterized by use of alcohol, cannabis, and poppers and the Licit Drug Use class (21.6%) was characterized by use of alcohol alone. The Party 'N' Play (PnP) class (2.3%) was characterized by use of crystal methamphetamine GHB, Poppers, and Erectile Drugs; The Multi-use (3.5%) class was characterized by the PnP substances plus alcohol and ecstasy; and the Cannabis + class was characterized by use of Cannabis, Erectile Drugs, and Ecstasy. Relative to the referent class, all other classes were associated with events with more behavioural and network risk factors for STBBIs-highlighting the need for harm reduction interventions for gbMSM who use these drugs.

Trends in sexually transmitted and blood-borne infections in China from 2005 to 2021: a joinpoint regression model.

BACKGROUND: Sexually transmitted and blood-borne infections (STBBIs) is a major public health concern in China. This study assessed the overall trends in STBBIs to improve the comprehensive understanding of the burden of STBBIs and provide evidence for their prevention and control. METHODS: Data for the period from 2005 to 2021 were analyzed across China on infections with hepatitis B or C; syphilis; gonorrhea; and HIV infection. Trends, annual percent change (APC), and average annual percent change (AAPC) in diagnosis rate was analyzed using joinpoint regression models for the five STBBIs together or individually. RESULTS: From 2005 to 2021, the overall diagnosis rate of all five STBBIs increased, with an AAPC of 1.3% [95% confidence interval (CI) -0.5% to 3.1%]. Diagnosis rates of HIV, syphilis and hepatitis C increased individually, but it decreased for infections of hepatitis B and gonorrhea. Joinpoint analysis identified four phases in diagnosis rate of hepatitis C; three phases in diagnosis rate of hepatitis B, HIV infection, and syphilis; two in diagnosis rate of gonorrhea infection. CONCLUSION: Despite national efforts to prevent and control STBBIs, their overall diagnosis rate has continued to rise in China, and they remain an important public health challenge. Further efforts should be made to educate the general population about STBBIs, particularly HIV. Interventions targeting vulnerable groups should be adopted and their efficacy monitored through regular analysis of trends.

Sexually transmitted and blood-borne infections by sex, methamphetamine use, and houselessness before, at, and after HIV diagnosis in Manitoba, Canada.

Objectives: Describe the proportion of people newly living with HIV with sexually transmitted and blood-borne infections (STBBIs) before, at, and after HIV diagnosis in Manitoba, Canada. Methods: A retrospective cohort study reviewed clinical charts of all 404 people ≥18 years old newly diagnosed with HIV in Manitoba, Canada between 2018 and 2021. Syphilis, hepatitis C and B, gonorrhea, and chlamydia infections before, at, and after HIV diagnosis were recorded and analyzed by sex at birth, injection drug use status, use of methamphetamines, and housing status. Results: A total of 53% of people were diagnosed with syphilis, 44.1% with gonorrhea, 42.8% with chlamydia, and 40.6% with hepatitis C at least once. Among females, 64.1% had at least one or more STBBIs diagnoses before HIV diagnosis compared with 44.8% of males. Over 70% of people experiencing houselessness had at least one STBBI diagnosis before their HIV diagnosis compared with 43.9% of people not houseless. Among people who used methamphetamines, 68.3% had one or more STBBIs before HIV diagnosis compared with 28.9% of people who do not use methamphetamines. In a multivariable analysis houselessness, methamphetamine use, and younger age were associated with increased risk of any STBBIs. Conclusions: In our Manitoba cohort of people living with HIV, disproportionately more females, people experiencing houselessness, and those who use methamphetamine were diagnosed with STBBIs. The proportion of new infections before HIV diagnoses highlights a missed opportunity to provide prevention modalities, including pre-exposure prophylaxis, and the proportion after HIV diagnosis emphasizes the importance of enhancing engagement, repeated testing, and educational strategies to ameliorate ongoing exposures.

Population-level effectiveness of pre-exposure prophylaxis for HIV prevention among men who have sex with men in Montréal (Canada): a modelling study of surveillance and survey data.

INTRODUCTION: HIV pre-exposure prophylaxis (PrEP) has been recommended and partly subsidized in Québec, Canada, since 2013. We evaluated the population-level impact of PrEP on HIV transmission among men who have sex with men (MSM) in Montréal, Québec's largest city, over 2013-2021. METHODS: We used an agent-based mathematical model of sexual HIV transmission to estimate the fraction of HIV acquisitions averted by PrEP compared to a counterfactual scenario without PrEP. The model was calibrated to local MSM survey, surveillance, and cohort data and accounted for COVID-19 pandemic impacts on sexual activity, HIV prevention, and care. PrEP was modelled from 2013 onwards, assuming 86% individual-level effectiveness. The PrEP eligibility criteria were: any anal sex unprotected by condoms (past 6 months) and either multiple partnerships (past 6 months) or multiple uses of post-exposure prophylaxis (lifetime). To assess potential optimization strategies, we modelled hypothetical scenarios prioritizing PrEP to MSM with high sexual activity (≥11 anal sex partners annually) or aged ⩽45 years, increasing coverage to levels achieved in Vancouver, Canada (where PrEP is free-of-charge), and improving retention. RESULTS: Over 2013-2021, the estimated annual HIV incidence decreased from 0.4 (90% credible interval [CrI]: 0.3-0.6) to 0.2 (90% CrI: 0.1-0.2) per 100 person-years. PrEP coverage among HIV-negative MSM remained low until 2015 (<1%). Afterwards, coverage increased to a maximum of 10% of all HIV-negative MSM, or about 16% of the 62% PrEP-eligible HIV-negative MSM in 2020. Over 2015-2021, PrEP averted an estimated 20% (90% CrI: 11%-30%) of cumulative HIV acquisitions. The hypothetical scenarios modelled showed that, at the same coverage level, prioritizing PrEP to high sexual activity MSM could have averted 30% (90% CrI: 19%-42%) of HIV acquisitions from 2015-2021. Even larger impacts could have resulted from higher coverage. Under the provincial eligibility criteria, reaching 10% coverage among HIV-negative MSM in 2015 and 30% in 2019, like attained in Vancouver, could have averted up to 63% (90% CrI: 54%-70%) of HIV acquisitions from 2015 to 2021. CONCLUSIONS: PrEP reduced population-level HIV transmission among Montréal MSM. However, our study suggests missed prevention opportunities and adds support for public policies that reduce PrEP barriers, financial or otherwise, to MSM at risk of HIV acquisition.

Improving access to test results for participants in bio-behavioural surveys of people who inject drugs.

Bio-behavioural surveys of people who inject drugs (PWID) evolved from unlinked anonymous monitoring (UAM) of human immunodeficiency virus (HIV) incidence and prevalence, which began in some high-income countries in the late 1980s. UAM was conducted purely for surveillance purposes and test results were not returned to participants. Later, the importance of collecting data on behavioural risk factors was recognised, leading to the development of bio-behavioural surveys of PWID, which today are conducted regularly in several countries. Typically, these surveys recruit participants from venues providing harm reduction services and involve behavioural questionnaires and dried blood spot (DBS) testing for HIV and hepatitis C (HCV). DBS test results are not returned to participants; instead, countries offer varied systems of on-site testing separate from the bio-behavioural testing or provide referrals to external testing services. In this commentary, we trace the history of bio-behavioural surveys of PWID from their origins to the present day to explain how the methodologies evolved, along with the ethical considerations underlying them. We highlight the dramatic improvements in treatments for HIV and HCV over the past thirty years and the corresponding need to ensure that bio-behavioural survey participants can access low-barrier and timely testing. We review the pros and cons of different strategies for providing test results to participants and argue that the return of DBS results collected as part of bio-behavioural surveys warrants consideration as an additional tool to improve testing access for participants. Any changes should be informed by the perspectives of participants, study site personnel and investigators.

Slipping through: mobility's influence on infectious disease risks for justice-involved women in Canada.

BACKGROUND: The relationship between incarceration and women's vulnerability to sexually transmitted and blood-borne infections (STBBI) is understudied in Canada, despite numerous studies showing that justice-involved women experience very high rates of infection. Justice-involved women in Canada are highly mobile, as a result of high rates of incarceration and extremely short sentences. From a public health perspective, it is productive to understand how the mobility of justice-involved women shapes their vulnerability to STBBI. RESULTS: This narrative review demonstrates that mobility between incarceration facilities and communities drives sexually transmitted and blood-borne disease risk for justice-involved women in Canada. Associations and interactions between epidemics of gender-based and intimate partner violence, substance use, and STBBIs shape the experiences of justice-involved women in Canada. In correctional facilities, the pre-existing vulnerability of justice-involved women is compounded by a lack of comprehensive STBBI care and limited harm reduction services. On release, unstable housing, disruptions to social support networks, interruptions in medical care, and relapse to or continuation of substance use, significantly increase individual disease risk and the likelihood of community transmission. High rates of incarceration for short periods perpetuate this cycle and complicate the delivery of healthcare. CONCLUSIONS: The review provides evidence of the need for stronger gender-transformative public health planning and responses for incarcerated women, in both federal and provincial corrections settings in Canada. A supportive, evidence-based approach to STBBI identification and treatment for incarcerated women - one that that removes stigma, maintains privacy and improves access, combined with structural policies to prevent incarceration - could decrease STBBI incidence and interrupt the cycle of incarceration and poor health outcomes. A coordinated and accountable program of reintegration that facilitates continuity of public health interventions for STBBI, as well as safe housing, harm reduction and other supports, can improve outcomes as well. Lastly, metrics to measure performance of STBBI management during incarceration and upon release would help to identify gaps and improve outcomes for justice-involved women in the Canadian context.

Translating evidence into practice with the National Advisory Committee on Sexually Transmitted and Blood-Borne Infections.

For over 30 years, the Government of Canada has developed guidelines on sexually transmitted and blood-borne infections (STBBI) with a group of subject matter experts. This expert group provided advice to the Public Health Agency of Canada (PHAC) from 2004 to 2019; transitioning to the National Advisory Committee on STBBI (NAC-STBBI) in 2019. NAC-STBBI supports PHAC's mandate to prevent and control infectious diseases by providing advice for the development of STBBI guidelines. The methodology for developing the NAC-STBBI recommendations is evolving to a more rigorous, systematic and transparent process that is consistent with current standards in guideline development. It is also informed by-and aligned with-the methods of several other major guideline developers. The methodology incorporates the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, as appropriate, when conducting evidence reviews and developing recommendations. Recommendations will be published on the canada.ca website with the supporting NAC-STBBI Statement detailing the methodology and evidence used to develop them. This process will ensure that PHAC provides trustworthy evidence-based STBBI recommendations to primary care providers and public health professionals.

A summary of the Pan-Canadian framework on sexually-transmitted and blood-borne infections.

Sexually-transmitted and blood-borne infections (STBBI) remain a significant health concern in Canada and around the world. To guide Canada's efforts to reduce the health impact of STBBI and to contribute to global efforts, a Pan-Canadian framework was developed and has been endorsed by federal, provincial and territorial ministers of health. The framework sets out an overarching and comprehensive approach to address STBBI. It has an integrated approach given the shared common risk factors, transmission routes, and affected populations. The framework establishes a vision for Canada where STBBI are rare and people living with STBBI receive the care and support they need. The success of the framework will be measured against the global STBBI targets and progress towards these strategic goals: reduce the incidence of STBBI in Canada; improve access to testing, treatment, and ongoing care and support; and reduce stigma and discrimination that create vulnerabilities to STBBI. The framework is composed of four interconnected pillars that span the continuum of STBBI care: prevention, testing, initiating care and treatment, and ongoing care and support. The framework recognizes that the creation of an enabling environment that includes interrelated legal, social, cultural, physical, and structural conditions supports successful STBBI programs, policies and actions. Through this framework, Canada is unifying and communicating a common approach to addressing STBBI while respecting the flexibility required by jurisdictions and sectors to address different needs and priorities. As outlined in the Pan-Canadian framework, federal, provincial, and territorial governments will develop indicators and targets for Canada that will permit them to measure Canada's progress and guide their respective priorities for all pillars of the framework.

Assessing risk behaviors and prevalence of sexually transmitted and blood-borne infections among female crack cocaine users in salvador - Bahia, Brazil

Crack cocaine use is associated with risky sexual behaviors and sexually transmitted infections (STIs), including HIV. We investigated sociodemographic and behavioral characteristics and infection rates in female crack cocaine users from impoverished communities of Salvador, Bahia, Brazil. A sample of 125 female crack cocaine users was recruited. Overall, the interviewees had low educational level and high rate of unemployment (close to 90 percent). One-third (37 percent) reported having traded sex for money or drugs, and 58 percent reported that they had not used condoms during intercourse in the last 30 days. The prevalence of infections was low: HIV-1.6 percent; HCV-2.4 percent; HBV- 0.8 percent; HTLV I/II-4.0 percent; and syphilis-4.0 percent. The combination of dire poverty and high prevalence of risk behaviors turn such populations a preferential target of initiatives aiming to reduce drug-related harm and promote social development. Low infection rates should not be viewed with complacency, but as a window of opportunity to implement prevention initiatives and reduce social marginalization.