Assessing the Temporality Between Transitions onto Opioid Agonist Therapy and Engagement with Antiretroviral Therapy in a Cohort of HIV-Positive People Who Use Opioids Daily.

A robust evidence-base describes the beneficial association between opioid agonist therapy (OAT) and HIV-related outcomes among people living with HIV and opioid use disorder. While some evidence suggests the stabilizing effect of OAT on antiretroviral therapy (ART) treatment engagement, less is understood about the potential for an inverse relationship. We sought to examine the relationship between transitions in ART engagement and transitions onto OAT. We used data from a prospective cohort of people living with HIV who use drugs in Vancouver, Canada-a setting with no-cost access to ART and low or no-cost access to OAT among low-income residents. Restricting the sample to those who reported daily or greater opioid use, we used generalized linear mixed-effects models to estimate the relationships between our primary outcome of transitions onto OAT (methadone or buprenorphine/naloxone) and transitions (1) onto ART and (2) into ART adherence. Subsequent analyses assessed the temporal sequencing of transitions. Between 2005 and 2017, among 433 participants, 48.3% reported transitioning onto OAT at least once. In concurrent analyses, transitions onto ART were positively and significantly associated with transitions onto OAT. Temporal sequencing revealed that transitions into OAT were also positively and significantly associated with subsequent transitions onto ART. OAT's potential to facilitate the uptake of ART points to the continued need to scale-up low-threshold, client-centered substance use services integrated alongside HIV care.

Utilization of Sexual Reproductive Health Services Among Youths in Malaysia: A Cross-Sectional Study Applying Andersen's Behavioral Model of Healthcare Utilization.

Background The sexual well-being of youths is crucial as it establishes the foundation for their sexual health throughout their lives. Malaysia's Ministry of Health (MOH) mainly delivers sexual reproductive health (SRH) services. Besides MOH, the National Population Family Development Board (NPFDB), under the purview of the Ministry of Women, Family and Community Development and Federation of Reproductive Health Association Malaysia, works closely with MOH to ensure the delivery of SRH information and services. Despite the availability of SRH services in Malaysia, it is uncertain whether youths are aware of and utilize these services. This study aims to identify factors that affect the utilization of SRH services among youths aged 18-24 years in Malaysia. Methodology This web-based, cross-sectional study was conducted from March 2022 to June 2022 using a self-administered pre-tested questionnaire. Andersen's Behavioral Model of Health Service Utilization was used to identify the variables included in the survey. Bivariate and multivariate logistic regression models were used to determine factors significantly associated with the utilization of SRH services. Adjusted odds ratio (AOR) and 95% confidence interval (CI) with a p-value <0.05 were considered to denote statistical significance. Results A total of 617 youths aged 18-24 years participated in the survey. Only 20.4% (n = 126) of youths had visited SRH services in their entire life, and only 8.4% (n = 52) of youths had visited SRH services in the past year. Predisposing factors such as age, marital status, exposure to SRH information from family and governmental agencies such as the NPFDB, enabling factors such as availability and comfort of SRH services, and need factors such as youths diagnosed with SRH-related diseases were significantly associated with SRH utilization. The older age group (20-24 years old) was more likely to utilize SRH services compared to the 18-19-year age group (AOR = 1.634, 95% CI = 1.041, 2.564, p = 0.033). Married participants were three times more likely to utilize SRH services than single participants (AOR = 2.910, 95% CI = 1.356, 6.249, p = 0.006). Participants who vaped had more odds of utilizing SRH services (AOR = 1.793, 95% CI = 1.014, 3.174, p = 0.045) The group of participants exposed to information on SRH from family had more odds of utilizing SRH service than those who did not receive information on SRH from the family (AOR = 1.964, 95% CI = 1.229, 3.138, p = 0.005). Likewise, participants who received SRH information from governmental agencies were more likely to utilize SRH services (AOR = 1.929, 95% CI = 1.202, 3.095, p = 0.006). Enabling factors that were associated with SRH utilization were the availability of services, described as self-buying medicine in pharmacies (AOR = 1.830, 95% CI = 1.184, 2.855, p = 0.007), and the comfortability of services (AOR = 1.928, 95% CI = 1.250, 2.974, p = 0.003). Youths who were diagnosed with SRH diseases (need factor) were four times more likely to utilize SRH services (AOR = 4.490, 95% CI = 1.935, 10.410, p < 0.001). Conclusions There is generally poor SRH service utilization and awareness among youths in Malaysia, which could be improved. The findings of this study can be used to influence SRH providers to offer a more age-targeted awareness program to meet the various SRH needs of youths.

Material Security Scale as a Measurement of Poverty among Key Populations At-Risk for HIV/AIDS in Malaysia: An Implication for People Who Use Drugs and Transgender People during the COVID-19 Pandemic.

The HIV epidemic is fueled by poverty; yet, methods to measure poverty remain scarce among populations at risk for HIV infection and disease progression to AIDS in Malaysia. Between August and November 2020, using data from a cross-sectional study of people who use drugs, (PWUD), transgender people, sex workers and men who have sex with men, this study examined the reliability and validity of a material security scale as a measurement of poverty. Additionally, we assessed factors associated with material security scores. We performed confirmatory factor analysis (CFA) for 268 study participants included in the analysis. A revised nine-item three-factor structure of the material security scale demonstrated an excellent fit in CFA. The revised material security score displayed good reliability, with Cronbach's alpha of 0.843, 0.826 and 0.818 for housing, economic resources and basic needs factors, respectively. In a subsequent analysis, PWUD and transgender people were less likely to present good material security scores during the pandemic, compared to their counterparts. The revised nine-item scale is a useful tool to assess poverty among key populations at-risk for HIV/AIDS with the potential to be extrapolated in similar income settings.

COVID-19 Impact on Healthcare and Supportive Services for People Who Use Drugs (PWUDs) in Malaysia.

Background: Restrictive orders and temporary programmatic or ad hoc changes within healthcare and other supportive systems that were implemented in response to the COVID-19 epidemic in Malaysia may have created hindrances to accessing healthcare and/or receiving other supportive services for people who use drugs (PWUDs). Design: A primarily qualitative study has been conducted to evaluate how service providers and recipients were adapting and coping during the initial periods of the COVID-19 response. Settings: The study engaged several healthcare and non-governmental organizations (NGOs) in the peninsular states of Penang, Kelantan, Selangor, and Melaka. Participants: Medical personnel of methadone maintenance treatment (MMT) programs (n = 2) and HIV clinics (n = 3), staff of NGO services (n = 4), and MMT patients (n = 9) were interviewed using a semi-structured format. Results: Interviewed participants reported significant organizational, programmatic, and treatment protocols related changes implemented within the healthcare and support services in addition to nationally imposed Movement Control Orders (MCOs). Changes aimed to reduce patient flow and concentration at the on-site services locations, including less frequent in-person visits, increased use of telemedicine resources, and greater reliance on telecommunication methods to maintain contacts with patients and clients; changes in medication dispensing protocols, including increased take-home doses and relaxed rules for obtaining them, or delivery of medications to patients' homes or locations near their homes were reported by the majority of study participants. No significant rates of COVID-19 infections among PWUDs, including among those with HIV have been reported at the study sites. Conclusions: Although the reported changes presented new challenges for both services providers and recipients and resulted in some degree of initial disruption, generally, all participants reported successful implementation and high levels of compliance with the newly introduced restrictions, regulations, and protocols, resulting in relatively low rates of treatment disruption or discontinuation at the study sites.

Material security and adherence to antiretroviral therapy among HIV-positive people who use illicit drugs.

OBJECTIVE: To examine the relationship between poverty, operationalized using a novel material security measure, and adherence to antiretroviral therapy (ART) among people who use illicit drugs (PWUD) in a context of universal access to HIV care. DESIGN: We analyzed data from a community-recruited prospective cohort in Vancouver, Canada (n = 623), from 2014 to 2017. METHODS: We used multivariable generalized mixed-effects analyses to estimate longitudinal factors associated with mean material security score. We then estimated the association between achieving at least 95% adherence to ART and overall mean material score, as well as mean score for three factors derived from a factor analysis. The three-factor structure, employed in the current analyses, were factor 1 (basic needs); factor 2 (housing-related variables) and factor 3 (economic resources). RESULTS: Recent incarceration [ß-coefficient (ß) = -0.176, 95% confidence interval (95% CI): -0.288 to -0.063], unmet health needs [ß = -0.110, 95% CI: -0.178 to -0.042), unmet social service needs (ß = -0.264, 95% CI: -0.336 to -0.193) and having access to social services (ß= -0.102, 95% CI: -0.1586 to -0.0465) were among the factors associated with lower material security scores. Contrary to expectations that low levels of material security in this population would lead to poor ART adherence, we did not observe a significant relationship between adherence and overall material security score, or for each factor individually. CONCLUSION: Our findings highlight the potentially important role of no-cost, universal access to HIV prevention and treatment, in mitigating the impact of socioeconomic disadvantage on ART adherence.

Receipt of opioid agonist treatment halves the risk of HIV-1 RNA viral load rebound through improved ART adherence for HIV-infected women who use illicit drugs.

BACKGROUND: Women living with HIV who use illicit drugs may be particularly vulnerable to HIV-1 RNA viral load (VL) rebound. METHODS: We used longitudinal data from 2006 to 2017 to evaluate the impact of sociodemographic, behavioral, social-structural, and clinical factors on the hazard of viral rebound for women enrolled in the ACCESS study, a prospective cohort with systematic VL monitoring. Women were included if they achieved VL suppression (<50 copies/mL) following antiretroviral therapy (ART) initiation and had more than one study interview. Sociodemographic as well as substance use, social-structural, addiction treatment, and HIV clinical factors were evaluated as predictors of viral rebound (VL > 1000 copies/mL). Cox regressions using a recurrent events framework, time-varying covariates, robust standard errors, and a frailty component were used. RESULTS: Of the 185 women included, 62 (34%) experienced at least one viral rebound event over an 11-year period, accumulating a total of 87 viral rebound events. In adjusted analysis, stimulant use more than doubled the hazard of viral rebound (adjusted hazard ratio [AHR]: 2.35, 95% confidence interval [CI]: 1.07-5.14) while the only factor protective against viral rebound was receipt of opioid agonist treatment (OAT) in the past six months (AHR: 0.46, 95% CI: 0.26-0.81). After adjusting for ART adherence in the past six months, the effect of OAT was attenuated (AHR: 0.57, 95% CI: 0.32-1.02). CONCLUSIONS: Efforts to improve access to and retention within OAT programs and decrease stimulant use may improve rates of viral suppression for HIV-positive women who use illicit drugs.

A Longitudinal Analysis of Daily Pill Burden and Likelihood of Optimal Adherence to Antiretroviral Therapy Among People Living With HIV Who Use Drugs.

OBJECTIVES: Among people living with HIV (PLWH), high levels of adherence to prescribed antiretroviral therapy (ART) is required to achieve optimal treatment outcomes. However, little is known about the effects of daily pill burden on adherence amongst PLWH who use drugs. We sought to investigate the association between daily pill burden and adherence to ART among members of this key population in Vancouver, Canada. METHODS: We used data from the AIDS Care Cohort to Evaluate Exposure to Survival Services study, a long-running community-recruited cohort of PLWH who use illicit drugs linked to comprehensive HIV clinical records. The longitudinal relationship between daily pill burden and the odds of ≥95% adherence to ART among ART-exposed individuals was analyzed using multivariable generalized linear mixed-effects modeling, adjusting for sociodemographic, behavioural, and structural factors linked to adherence. RESULTS: Between December 2005 and May 2014, the study enrolled 770 ART-exposed participants, including 257 (34%) women, with a median age of 43 years. At baseline, 437 (56.7%) participants achieved ≥95% adherence in the previous 180 days. Among all interview periods, the median adherence was 100% (interquartile range 71%-100%). In a multivariable model, a greater number of pills per day was negatively associated with ≥95% adherence (adjusted odds ratio [AOR] 0.87 per pill, 95% confidence interval [CI] 0.84-0.91). Further analysis showed that once-a-day ART regimens were positively associated with optimal adherence (AOR 1.39, 95% CI 1.07-1.80). CONCLUSIONS: In conclusion, simpler dosing demands (ie, fewer pills and once-a-day single tablet regimens) promoted optimal adherence among PLWH who use drugs. Our findings highlight the need for simpler dosing to be encouraged explicitly for PWUD with multiple adherence barriers.