Food insufficiency, housing and health-related quality of life: results from the Positive Spaces, Healthy Places study.

Studies of people living with HIV who are homeless or unstably housed show a high prevalence of food insufficiency (>50%) and associated poor health outcomes; however, most evidence is in the form of cross-sectional studies. To better understand this issue, we conducted a longitudinal study to examine the impact of food insufficiency and housing instability on overall physical and mental health-related quality of life (HRQoL) among people living with HIV in Ontario. Six hundred and two adults living with HIV were enrolled in the Positive Spaces, Healthy Places study and followed from 2006 to 2009. Interviewer-administered questionnaires were used, and generalized linear mixed-effects models constructed to examine longitudinal associations between food insufficiency, housing instability and physical and mental HRQoL. At baseline, 57% of participants were classified as food insufficient. After adjusting for potential confounders, longitudinal analyses revealed a significant, negative association between food insufficiency and physical and mental HRQoL outcomes, respectively [effect size (ES) with 95% confidence interval (CI): (ES = -2.1, CI = -3.9,-0.3); (ES = -3.5, CI = -6.1,-1.5)]. Furthermore, difficulties meeting housing costs were shown to have additional negative impacts on mental HRQoL. Food insufficiency is highly prevalent among people living with HIV in Ontario, particularly for those with unstable housing. This vulnerable group of individuals is in urgent need of changes to current housing programmes, services and policies, as well as careful consideration of their unmet nutritional needs.

Measuring food and nutrition security: tools and considerations for use among people living with HIV.

As an increasing number of countries implement integrated food and nutrition security (FNS) and HIV programs, global stakeholders need clarity on how to best measure FNS at the individual and household level. This paper reviews prominent FNS measurement tools, and describes considerations for interpretation in the context of HIV. There exist a range of FNS measurement tools and many have been adapted for use in HIV-endemic settings. Considerations in selecting appropriate tools include sub-types (food sufficiency, dietary diversity and food safety); scope/level of application; and available resources. Tools need to reflect both the needs of PLHIV and affected households and FNS program objectives. Generalized food sufficiency and dietary diversity tools may provide adequate measures of FNS in PLHIV for programmatic applications. Food consumption measurement tools provide further data for clinical or research applications. Measurement of food safety is an important, but underdeveloped aspect of assessment, especially for PLHIV.

Food security in the context of HIV: towards harmonized definitions and indicators.

Integration of HIV and food security services is imperative to improving the health and well-being of people living with HIV. However, consensus does not exist on definitions and measures of food security to guide service delivery and evaluation in the context of HIV. This paper reviews definitions and indicators of food security used by key agencies; outlines their relevance in the context of HIV; highlights opportunities for harmonized monitoring and evaluation indicators; and discusses promising developments in data collection and management. In addition to the commonly used dimensions of food availability, access, utilization and stability, we identify three components of food security-food sufficiency, dietary quality, and food safety-that are useful for understanding and measuring food security needs of HIV-affected and other vulnerable people. Harmonization across agencies of food security indicators in the context of HIV offers opportunities to improve measurement and tracking, strengthen coordination, and inform evidence-based programming.

Food insufficiency is associated with psychiatric morbidity in a nationally representative study of mental illness among food insecure Canadians.

PURPOSE: Studies suggest that people who are food insecure are more likely to experience mental illness. However, little is known about which aspects of food insecurity place individuals most at risk of mental illness. The purpose of this study was to establish the prevalence of mental illness among food insecure Canadians, and examine whether mental illness differs between those who are consuming insufficient amounts of food versus poor quality foods. METHODS: This analysis utilized the publically available dataset from the Canadian Community Health Survey cycle 4.1. Bivariable and multivariable logistic regression were used to examine the associations between food insecurity and mental health disorder diagnosis, while adjusting for potential confounders. Stratified analyses were used to identify vulnerable sub-groups. RESULTS: Among 5,588 Canadian adults (18-64 years) reporting food insecurity, 58 % reported poor food quality and 42 % reported food insufficiency. The prevalence of mental health diagnosis was 24 % among participants with poor food quality, and 35 % among individuals who were food insufficient (hunger). After adjusting for confounders, adults experiencing food insufficiency had 1.69 adjusted-odds [95 % confidence interval (CI): 1.49-1.91] of having a mental health diagnosis. Stratified analyses revealed increased odds among women (a-OR 1.89, 95 % CI 1.62-2.20), single parent households (a-OR 2.05, 95 % CI 1.51-2.78), and non-immigrants (a-OR 1.88, 95 % CI 1.64-2.16). CONCLUSION: The prevalence of mental illness is alarmingly high in this population-based sample of food insecure Canadians. These findings suggest that government and community-based programming aimed at strengthening food security should integrate supports for mental illness in this population.

Managing stigma in adolescent HIV: silence, secrets and sanctioned spaces.

HIV is conceived as a disease that combines stigma elements of perceived contagion and socially undesirable behaviours. Drawing on in-depth interviews with professional adolescent service providers from Australia, Canada, the UK and the USA, this paper explores HIV stigma and stigma management in the lives of HIV-positive young people. Findings elucidate how additional layers of stigma relating to 'adolescent rights' and 'embodied innocence' are added to HIV stigma as it is more usually conceived. This study suggests that managing this stigma entails managing silence in the context of the social worlds of the young person, the family and the service provider. Silence emerged as a key theme in the participant narratives and was embedded in the descriptions of young people's lived experiences. Crucially, silence is a product of oppression and inequity but is also a tool for resistance. Silence defends secrets and exists in the spaces, both physical and social, that are created for them in order to manage the stigma in young people's lives. Silences associated with HIV therefore need to be exposed if we are to better understand what HIV truly means to seropositive young people and how 'silences' may minimise or exacerbate their experience of HIV stigma inside and outside the context of programmes.

Predicting hospitalization among HIV-infected antiretroviral naïve patients starting HAART: determining clinical markers and exploring social pathways.

In the era of highly active antiretroviral therapy (HAART), hospitalization as a measure of morbidity has become of increasing interest. The objectives of this study were to determine clinical predictors of hospitalization among HIV-infected persons initiating HAART and to explore the impact of gender and drug use on hospitalization. The analysis was based on a cohort of HIV-positive individuals initiating HAART between 1996 and 2001. Information on hospitalizations was obtained through data linkage with the BC Ministry of Health. Cox-proportional hazard models were used to assess variables associated with time to hospitalization. A total of 1,605 people were eligible and 672 (42%) were hospitalized for one or more days. The final multivariate model indicated that there was an increased risk of hospitalization among those with high baseline HIV RNA (HR for > 100,000 copies/mL: 1.26; 95%CI: 1.16-1.59) or low CD4 cell counts (HR [95% CI] compared to > or = 200 cells/mm3: 1.62 [1.28-2.06] and 1.29 [1.07-1.56] for < 50 and 50-199 cells/mm(3), respectively). Other factors, including adherence, previous hospitalization, gender and injection drug use remained predictive of hospitalization. These findings highlight the importance of closely monitoring patients starting therapy with low CD4 cell counts in order to mediate or prevent outcomes requiring hospitalization.

Nonadherence increases the risk of hospitalization among HIV-infected antiretroviral naive patients started on HAART.

BACKGROUND: Since the advent of highly active antiretroviral therapy (HAART), AIDS-related hospitalizations have decreased. The objective of this study was to assess the impact of adherence on hospitalization among antiretroviral-naïve HIV-infected persons initiating HAART. METHODS: Analysis was based on a cohort of individuals initiating HAART between 1996 and 2001. The primary outcome was hospitalization for one or more days. Survival methods were used to assess the impact of adherence on hospitalization. RESULTS: Of 1605 eligible participants, 672 (42%) were hospitalized for one or more days after initiating HAART. Median adherence levels were 92 (IQR: 58, 100) and 100 (IQR: 83, 100) among those ever and never hospitalized, respectively. After controlling for confounders, those with <95% adherence had 1.88 times (95% CI: 1.60, 2.21) higher risk for hospitalization. CONCLUSIONS: Suboptimal adherence among HIV-infected patients taking HAART predicts hospitalization. Identifying and addressing factors contributing to poor adherence early in treatment could improve patient care and lower hospitalization costs.

It's time for Canadian community early warning systems for illicit drug overdoses.

Although fatal and non-fatal overdoses represent a significant source of morbidity and mortality, current systems of surveillance and communication in Canada provide inadequate measurement of drug trends and lack a timely response to drug-related hazards. In order for an effective early warning system for illicit drug overdoses to become a reality, a number of elements will be required: real-time epidemiologic surveillance systems for illicit drug trends and overdoses, inter-agency networks for gathering data and disseminating alerts, and mechanisms for effectively and respectfully engaging with members of drug using communities. An overdose warning system in an urban area like Vancouver would ideally be imbedded within a system that monitors drug trends and overdoses by incorporating qualitative and quantitative information obtained from multiple sources. Valuable information may be collected and disseminated through community organizations and services associated with public health, emergency health services, law enforcement, medical laboratories, emergency departments, community-based organizations, research institutions and people with addiction themselves. The present paper outlines considerations and conceptual elements required to guide implementation of such systems in Canadian cities such as Vancouver.

Association between Food Insecurity and Procurement Methods among People Living with HIV in a High Resource Setting.

OBJECTIVE: People living with HIV in high-resource settings suffer severe levels of food insecurity; however, limited evidence exists regarding dietary intake and sub-components that characterize food insecurity (i.e. food quantity, quality, safety or procurement) in this population. We examined the prevalence and characteristics of food insecurity among people living with HIV across British Columbia, Canada. DESIGN: This cross-sectional analysis was conducted within a national community-based research initiative. METHODS: Food security was measured using the Health Canada Household Food Security Scale Module. Logistic regression was used to determine key independent predictors of food insecurity, controlling for potential confounders. RESULTS: Of 262 participants, 192 (73%) reported food insecurity. Sub-components associated with food insecurity in bivariate analysis included: < RDI consumption of protein (p = 0.046); being sick from spoiled/unsafe food in the past six months (p = 0.010); and procurement of food using non-traditional methods (p <0.05). In multivariable analyses, factors significantly associated with food insecurity included: procurement of food using non-traditional methods [AOR = 11.11, 95% CI: 4.79-25.68, p = <0.001]; younger age [AOR = 0.92, 95% CI: 0.86-0.96, p = <0.001]; unstable housing [AOR = 4.46, 95% CI: 1.15-17.36, p = 0.031]; household gross annual income [AOR = 4.49, 95% CI: 1.74-11.60, p = 0.002]; and symptoms of depression [AOR = 2.73, 95% CI: 1.25-5.96, p = 0.012]. CONCLUSIONS: Food insecurity among people living with HIV in British Columbia is characterized by poor dietary quality and food procurement methods. Notably, participants who reported procuring in non-traditional manners were over 10 times more likely to be food insecure. These findings suggest a need for tailored food security and social support interventions in this setting.

"Walking along beside the researcher": how Canadian REBs/IRBs are responding to the needs of community-based participatory research.

Research ethics boards and institutional review boards (REBs/IRBs) have been criticized for relying on conceptions of research that privilege biomedical, clinical, and experimental designs, and for penalizing research that deviates from this model. Studies that use a community-based participatory research (CBPR) design have been identified as particularly challenging to navigate through existing ethics review frameworks. However, the voices of REB/IRB members and staff have been largely absent in this debate. The objective of this article is to explore the perspectives of members of Canadian university-based REBs/IRBs regarding their capacity to review CBPR protocols. We present findings from interviews with 24 Canadian REB/IRB members, staff, and other key informants. Participants were asked to describe and contrast their experiences reviewing studies using CBPR and mainstream approaches. Contrary to the perception that REBs/IRBs are inflexible and unresponsive, participants described their attempts to dialogue and negotiate with researchers and to provide guidance. Overall, these Canadian REBs/IRBs demonstrated a more complex understanding of CBPR than is typically characterized in the literature. Finally, we situate our findings within literature on relational ethics and explore the possibility of researchers and REBs/IRBs working collaboratively to find solutions to unique ethical tensions in CBPR.

Individual and structural vulnerability among female youth who exchange sex for survival.

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.

Key considerations for logic model development in research partnerships: a Canadian case study.

Community-academic partnership research is a fairly new genre of community-based participatory research. It has arisen in part, from recognition of the potential role of alliances in the development and translation of applied knowledge and the elimination of health disparities. This paper reports on the learning process of academic and community members who worked together in developing a logic model for a research program focusing on partnerships with vulnerable populations. The Partners in Community Health Research is a 6-year training program that seeks to combine research, training, and practice through the work of its "learning clusters". As these types of partnerships proliferate, the articulation and exploration of clear models will assist in their implementation. The authors, coming from both academia and community agencies, present a logic model meant to facilitate program management. Key considerations in the model's development are discussed in the context of an ongoing research partnership; namely, the complexity of the research partnership, power and accountability, alignment with health promotion policy, and the iterative nature of program design. Recommendations challenge academics, policy-makers, service providers, and community members to reflect on the elements needed to support and manage research partnerships and the tools necessary to ensure continued collaboration.