Precarious Housing Associated with Unsuppressed Viral load, sub-optimal Access to HIV Treatment and Unmet Health care Needs, Among Women Living with HIV in Metro Vancouver, Canada.

We investigated associations between (1) housing status (four categories measuring housing stability) and outcomes along the HIV care continuum (not currently on antiretroviral therapy [ART]; sub-optimal ART adherence [< 95% in the last 3-4 weeks]; unsuppressed viral load [> 200 copies/ml], median CD4 < 200 in the last six months), and (2) housing status and unmet primary, dental and mental health care needs in the last six months among WLWH. Housing status was defined according to the Canadian Definition of Homelessness and had four categories: unsheltered (i.e., living in ≥ 1 unsheltered location [e.g., street, abandoned buildings]), unstable (i.e., living in ≥ 1 unstable location [e.g., shelter, couch surfing]), supportive housing (i.e., only living in supportive housing), and stable housing (i.e., only living in one's own housing; reference). At baseline, in the last six months, 47.3% of participants reported unstable housing, followed by 24.4% unsheltered housing, 16.4% stable housing, and 11.9% supportive housing. Overall, 19.1% of the full sample (N = 336, 2010-2019) reported not currently on ART; among participants on ART, 28.0% reported sub-optimal ART adherence. Overall, 32.1% had recent unsuppressed viral load. Among a subsample (n = 318, 2014-2019), 15.7% reported unmet primary care needs, 26.1% unmet dental care needs, and 16.4% unmet mental health care needs. In adjusted models, being unsheltered (vs. stable housing) was associated with not currently on ART, unsuppressed viral load, and unmet primary and dental care needs. Housing and health services need to be developed with and for WLWH to address structural inequities and fulfill basic rights to housing and health.

Suspected involvement of fentanyl in prior overdoses and engagement in harm reduction practices among young adults who use drugs.

Background: From 2011 to 2016, the United States has experienced a 55% increase in overall overdose deaths and a 260% increase in fatal fentanyl-related overdoses. Increasing engagement in harm reduction practices is essential to reducing the rate of fentanyl-related overdoses. This study sought to examine the uptake of harm reduction practices among young adults who reported recent drug use and who were recruited for a study to assess the utility and acceptability of rapid fentanyl test strips. Methods: Between May and October 2017, 93 young adults who reported drug use in the past 30 days were recruited through word of mouth, Internet advertising, and public canvasing. Participants completed an interviewer-administered survey that assessed participants' sociodemographic and behavioral characteristics, suspected fentanyl exposure, and overdose history. We assessed harm reduction practices and other correlates associated with experiencing a suspected fentanyl-related overdose. Results: Of 93 eligible participants, 36% (n = 34) reported ever having experienced an overdose, among whom 53% (n = 18) suspected having experienced a fentanyl-related overdose. Participants who had ever experienced a fentanyl-related overdose were more likely to keep naloxone nearby when using drugs compared with those who had never experienced an overdose and those who had experienced an overdose that they did not suspect was related to fentanyl (P < .001). Additionally, experiencing a suspected fentanyl-related overdose was associated with having previously administered naloxone to someone else experiencing an overdose (P < .001). Conclusion: Those who had experienced a suspected fentanyl-related overdose were more likely to carry and administer naloxone. Future overdose prevention interventions should involve persons who have experienced a suspected fentanyl overdose and/or responded to an overdose in order to develop harm reduction programs that meet the needs of those at risk of an overdose.

Results of a participatory needs assessment demonstrate an opportunity to involve people who use alcohol in drug user activism and harm reduction.

BACKGROUND: Drug users' organizations have made progress in recent years in advocating for the health and human rights of people who use illicit drugs but have historically not emphasized the needs of people who drink alcohol. METHODS: This paper reports on a qualitative participatory needs assessment with people who use illicit substances in British Columbia, Canada. We held workshops in 17 communities; these were facilitated by people who use illicit drugs, recorded with ethnographic fieldnotes, and analyzed using critical theory. RESULTS: Although the workshops were targeted to people who use illicit drugs, people who primarily consume alcohol also attended. An unexpected finding was the potential for drug users' organizations and other harm reduction programs to involve "illicit drinkers": people who drink non-beverage alcohol (e.g. mouthwash, rubbing alcohol) and those who drink beverage alcohol in criminalized ways (e.g., homeless drinkers). Potential points of alliance between these groups are common priorities (specifically, improving treatment by health professionals and the police, expanding housing options, and implementing harm reduction services), common values (reducing surveillance and improving accountability of services), and polysubstance use. CONCLUSIONS: Despite these potential points of alliance, there has historically been limited involvement of illicit drinkers in drug users' activism. Possible barriers to involvement of illicit drinkers in drug users' organizations include racism (as discourses around alcohol use are highly racialized), horizontal violence, the extreme marginalization of illicit drinkers, and knowledge gaps around harm reduction for alcohol. Understanding the commonalities between people who use drugs and people who use alcohol, as well as the potential barriers to alliance between them, may facilitate the greater involvement of illicit drinkers in drug users' organizations and harm reduction services.

Awareness and knowledge of the Good Samaritan Drug Overdose Act among people at risk of witnessing an overdose in British Columbia, Canada: a multi-methods cross sectional study.

INTRODUCTION: Bystanders to drug overdoses often avoid or delay calling 9-1-1 and cite fear of police involvement as a main reason. In 2017, the Good Samaritan Drug Overdose Act (GSDOA) was enacted by the Canadian government to provide people present at an overdose with legal protection from charges for simple drug possession, and conditions stemming from simple possession. Few studies have taken a multi-methods approach to evaluating the GSDOA. We used quantitative surveys and qualitative interviews to explore awareness, understanding, and perceptions of the GSDOA in people at risk of witnessing an overdose. METHODS: Quantitative cross-sectional surveys and qualitative telephone interviews were conducted with adults and youth at risk of witnessing an overdose across British Columbia. Cross-sectional survey participants were recruited at 19 Take Home Naloxone sites and online through Foundry. Multivariable logistic regression models were constructed hierarchically to determine factors associated with GSDOA awareness. Telephone interview participants were recruited by research assistants with lived/living experience of substance use. Deductive and inductive thematic analyses were conducted to identify major themes. RESULTS: Overall, 52.7% (n = 296) of the quantitative study sample (N = 453) reported being aware of the GSDOA. In multivariable analysis, cellphone possession (adjusted odds ratio [AOR] = 2.19; 95% confidence interval [CI] 1.36, 3.54) and having recently witnessed an opioid overdose (AOR = 2.34; 95% CI 1.45, 3.80) were positively associated with GSDOA awareness. Young adults (25 - 34 years) were more likely to be aware of the Act (AOR = 2.10; 95% CI 1.11, 3.98) compared to youth (16-24 years). Qualitative interviews (N = 42) revealed that many overestimated the protections offered by the GSDOA. To increase awareness and knowledge of the Act among youth, participants recommended adding the GSDOA to school curricula and using social media. Word of mouth was suggested to reach adults. CONCLUSION: Both awareness and knowledge of the GSDOA remain low in BC, with many overestimating the protections the Act offers. Dissemination efforts should be led by people with lived/living experience and should target those with limited awareness and understanding of the Act as misunderstandings can erode trust in law enforcement and harm reduction policy.

Cohort profile: development and characteristics of a retrospective cohort of individuals dispensed prescription opioids for non-cancer pain in British Columbia, Canada.

PURPOSE: Prescription opioids (POs) are widely prescribed for chronic non-cancer pain but are associated with several risks and limited long-term benefit. Large, linked data sources are needed to monitor their harmful effects. We developed and characterised a retrospective cohort of people dispensed POs. PARTICIPANTS: We used a large linked administrative database to create the Opioid Prescribing Evaluation and Research Activities cohort of individuals dispensed POs for non-cancer pain in British Columbia (BC), Canada (1996-2015). We created definitions to categorise episodes of PO use based on a review of the literature (acute, episodic, chronic), developed an algorithm for inferring clinical indication and assessed patterns of PO use across a range of characteristics. FINDINGS TO DATE: The current cohort includes 1.1 million individuals and 3.4 million PO episodes (estimated to capture 40%-50% of PO use in BC). The majority of episodes were acute (81%), with most prescribed for dental or surgical pain. Chronic use made up 3% of episodes but 88% of morphine equivalents (MEQ). Across the acute to episodic to chronic episode gradient, there was an increasing prevalence of higher potency POs (hydromorphone, oxycodone, fentanyl, morphine), long-acting formulations and chronic pain related indications (eg, back, neck, joint pain). Average daily dose (MEQ) was similar for acute/episodic but higher for chronic episodes. Approximately 7% of the cohort had a chronic episode and chronic pain was the characteristic most strongly associated with chronic PO use. Individuals initiating a chronic episode were also more likely to have higher social/material deprivation and previous experience with a mental health condition or a problem related to alcohol or opioid use. Overall, these findings suggest our episode definitions have face validity and also provide insight into characteristics of people initiating chronic PO therapy. FUTURE PLANS: The cohort will be refreshed every 2 years. Future analyses will explore the association between POs and adverse outcomes.

Correlates of seeking emergency medical help in the event of an overdose in British Columbia, Canada: Findings from the Take Home Naloxone program.

BACKGROUND: British Columbia (BC), Canada, is experiencing an unprecedented number of opioid overdoses mainly due to the contamination of illicit drugs with fentanyl and its analogues. Reluctance to seek emergency medical help (i.e., by calling 9-1-1) has been identified as a barrier to optimal care for overdose victims. This study aimed to identify the correlates of seeking help during an overdose event when naloxone was administered via BC's Take Home Naloxone (THN) program. METHODS: In this cross-sectional study, we reviewed administrative records (from July 2015 to December 2017) about overdose events submitted by THN participants when they received their replacement naloxone kits (n = 2350). The primary outcome of the study was reported calling 9-1-1 and modified Poisson regression models were built to investigate the factors associated with help-seeking during an overdose event. RESULTS: Most overdose victims were men (69.0%) and >30 years old (61.5%). Overall, participants reported calling 9-1-1 in 1310 (55.7%) overdose events. In the multivariable model, the likelihood of calling 9-1-1 was significantly and positively associated with the overdose victim being male and receiving rescue breathing. The likelihood of calling 9-1-1 was significantly and negatively associated with the overdoses occurring in private residences and health regions other than Vancouver Coastal which delivers services to mostly urban residents. CONCLUSION: Overall, medical help was sought for 55.7% of overdoses where naloxone was administered. Overdoses occurring among male victims as well as those receiving higher doses of naloxone and mouth-to-mouth rescue breathing were associated with a higher likelihood of help-seeking by responders. Future interventions need to encourage people who witness an overdose to seek emergency medical help.

Perceived harms and harm reduction strategies among people who drink non-beverage alcohol: Community-based qualitative research in Vancouver, Canada.

BACKGROUND: There has been increasing interest in harm reduction initiatives for street-involved people who drink alcohol, including non-beverage alcohol such as mouthwash and hand sanitizer. Limited evidence exists to guide these initiatives, and a particular gap is in research that prioritizes the experiences and perspectives of drinkers themselves. This research was conducted to explore the harms of what participants termed "illicit drinking" as perceived by people who engage in it, to characterize the steps this population takes to reduce harms, and to identify additional interventions that may be of benefit. METHODS: This participatory qualitative research drew on ethnographic approaches including a series of 14″town hall"-style meetings facilitatied and attended by people who self identify as drinking illicit or non-beverage alcohol (n = 60) in Vancouver, British Columbia. This fieldwork was supplemented with four focus groups to explore emerging issues. RESULTS: Participants in the meetings described the harms they experienced as including unintentional injury; harms to physical health; withdrawal; violence, theft, and being taken advantage of; harms to mental health; reduced access to services; and interactions with police. Current harm reduction strategies involved balancing the risks and benefits of drinking in groups and adopting techniques to avoid withdrawal. Proposed future initiatives included non-residential managed alcohol programs and peer-based supports. CONCLUSIONS: Illicit drinkers describe harms and harm reductions strategies that have much in common with those of other illicit substances, and can be interpreted as examples of and responses to structural and everyday violence. Understanding the perceived harms of alcohol use by socially marginalized drinkers and their ideas about harm reduction will help tailor programs to meet their needs.

Factors that support successful transition to the community among women leaving prison in British Columbia: a prospective cohort study using participatory action research.

BACKGROUND: In Canada, the number of women sentenced to prison has almost doubled since 1995. In British Columbia, the rate of reincarceration is 70% within 2 years. Our aim was to identify factors associated with recidivism among women in British Columbia. METHODS: We prospectively followed women after discharge from provincial corrections centres in British Columbia. We defined recidivism as participation in criminal activity disclosed by participants during the year following release. To identify predictive factors, we carried out a repeated-measures analysis using a logistic mixed-effect model. RESULTS: Four hundred women completed a baseline interview, of whom 207 completed additional interviews during the subsequent year, contributing 395 interviews in total. Factors significantly associated in univariate analysis with recidivism included not having a family doctor or dentist, depression, not having children, less than high school education, index charge of drug offense or theft under $5000, poor general health, hepatitis C treatment, poor nutritional or spiritual health, and use of cannabis or cocaine. In multivariate analysis, good nutritional health (odds ratio [OR] 0.52 [95% confidence interval (CI) 0.35-0.76]), good spiritual health (OR 0.61 [95% CI 0.44-0.83]), high school education (OR 0.44 [95% CI 0.22-0.87]) and incarceration for a drug offence versus other crimes (OR 0.30 [95% CI 0.12-0.79]) were protective against recidivism. INTERPRETATION: Our findings emphasize the relevance of health-related strategies as drivers of recidivism among women released from prison. Health assessment on admission followed by treatment for trauma and associated psychiatric disorders and for chronic medical and dental problems deserve consideration as priority approaches to reduce rates of reincarceration.