Process evaluation of the Prevent Overdose in Toronto (POINT) program.

SETTING: A harm reduction program at a public health unit in Toronto, Ontario, between August 31, 2011 and August 31, 2013. INTERVENTION: We conducted a process evaluation of the first two years of an opioid overdose prevention and response program, Prevent Overdose in Toronto (POINT), including analysis of data from program documentation forms, as well as qualitative interviews with program staff, representatives from partner agencies, and program clients. OUTCOMES: In the first two years of the program, 662 individuals (52.4% male; mean age 38.3 years) were trained in opioid overdose prevention and given a naloxone kit. Among clients currently using opioids, the most frequently reported opioids were oxycodone (40.4%) and heroin (34.4%). Clients reported 98 administrations of naloxone, primarily to friends and acquaintances. Nearly all naloxone recipients reportedly survived; one did not survive, and one had an unknown outcome.Staff and partner agencies feel the program reaches the target population and that POINT training meets clients' needs. Clients would like to see the training offered more widely. Overall, staff, partner agencies and clients were pleased with the POINT program, and they offered suggestions on program recruitment and delivery. IMPLICATIONS: Individuals at risk of opioid overdose have participated in overdose prevention and response training, and reported using naloxone in overdose events. Results of this initial program evaluation are being used to improve the delivery of the POINT program and can inform broader public health practice in opioid overdose prevention.

Beyond viral response: A prospective evaluation of a community-based, multi-disciplinary, peer-driven model of HCV treatment and support.

BACKGROUND: Although the majority of new cases of hepatitis C (HCV) occur among people who inject drugs, very few receive treatment. In response, low-barrier, multidisciplinary models of HCV treatment have emerged in recent years to serve illicit drug users and have demonstrated comparable outcomes to the care delivered in tertiary care settings. However, few studies have measured comprehensive outcomes of these models. METHODS: The Toronto Community Hep C Program (TCHCP) is a community-based partnership between three primary health care centres with integrated specialist support. Program clients were interviewed using standardized questionnaires at three time points (baseline, post completion of HCV support group, and one year post group completion). The primary outcome of this study was self-reported overall health. Secondary outcomes included mental health, substance use, housing and income stability, and access to health care. RESULTS: TCHCP clients reported high rates of poverty, histories of trauma and incarceration. Physical and mental health co-morbidities were also very common; 78% reported having at least one chronic medical problem in addition to HCV and 41% had a lifetime history of hospitalization for mental health reasons. Participation in the program improved access to HCV care. Prior to joining the TCHCP, only 15% had been assessed by a HCV specialist. By the end of the study period this had increased significantly to 54%. Self-reported overall health did not improve during the study period. Housing status and income showed significant improvement. The proportion of participants with stable housing increased from 54% to 76% during the study period (p=0.0017) and the proportion of patients receiving income from provincial disability benefits also increased significantly (55% vs 75%, p=0.0216). CONCLUSION: This study demonstrated that a multi-disciplinary, community-based model of HCV treatment improves participant's lives in ways that extend beyond hepatitis C.

Hepatitis C virus seroconversion among HIV-positive men who have sex with men with no history of injection drug use: Results from a clinical HIV cohort.

BACKGROUND: Internationally, there is a growing recognition that hepatitis C virus (HCV) may be sexually transmitted among HIV-positive men who have sex with men (MSM). OBJECTIVE: To report the first Canadian estimate of HCV seroincidence in 2000 to 2010 and its risk factors among HIV-positive MSM with no known history of injection drug use. METHODS: Data from the Ontario HIV Treatment Network Cohort Study, an ongoing cohort of individuals in HIV care in Ontario, were analyzed. Data were obtained from medical charts, interviews and record linkage with the provincial public health laboratories. The analysis was restricted to 1534 MSM who did not report injection drug use and had undergone ≥2 HCV antibody tests, of which the first was negative (median 6.1 person-years [PY] of follow-up; sum 9987 PY). RESULTS: In 2000 to 2010, 51 HCV seroconversions were observed, an overall incidence of 5.1 per 1000 PY (95% CI 3.9 to 6.7). Annual incidence varied from 1.6 to 8.9 per 1000 PY, with no statistical evidence of a temporal trend. Risk for seroconversion was elevated among men who had ever had syphilis (adjusted HR 2.5 [95% CI 1.1 to 5.5) and men who had acute syphilis infection in the previous 18 months (adjusted HR 2.8 [95% CI 1.0 to 7.9]). Risk was lower for men who had initiated antiretroviral treatment (adjusted HR 0.49 [95% CI 0.25 to 0.95]). There were no statistically significant effects of age, ethnicity, region, CD4 cell count or HIV viral load. CONCLUSIONS: These findings suggest that periodic HCV rescreening may be appropriate in Ontario among HIV-positive MSM. Future research should seek evidence whether syphilis is simply a marker for high-risk sexual behaviour or networks, or whether it potentiates sexual HCV transmission among individuals with HIV.

HISTORIQUE: Sur la scène internationale, il apparaît de plus en plus clairement que le virus de l'hépatite C (VHC) peut être transmis sexuellement entre hommes positifs au VIH ayant des relations sexuelles avec des hommes (HARSAH). OBJECTIF: Rendre compte de la première estimation canadienne de la séro-incidence de VHC entre 2000 et 2010 et de ses facteurs de risque chez les HARSAH positifs au VIH sans antécédents connus de consommation de drogues injectables. MÉTHODOLOGIE: Les chercheurs ont analysé les données de l'Ontario HIV Treatment Network Cohort Study, une cohorte continue de personnes soignées pour le VIH en Ontario. Ils ont tiré les données de dossiers médicaux, d'entrevues et de liens entre les dossiers et les laboratoires provinciaux de santé publique. Ils ont restreint l'analyse à 1 534 HARSAH qui ne déclaraient pas consommer de drogues injectables et qui avaient subi au moins deux tests d'anticorps du VHC, dont le premier était négatif (suivi médian de 6,1 années-personne [AP]; somme de 9 987 AP). RÉSULTATS: De 2000 à 2010, les chercheurs ont observé 51 cas de séroconversion au VHC, pour une incidence globale de 5,1 cas sur 1 000 AP (95 % IC 3,9 à 6,7). L'incidence annuelle variait entre 1,6 et 8,9 cas sur 1 000 AP, sans preuve statistique de tendance temporelle. Le risque de séroconversion était élevé chez les hommes qui n'avaient jamais eu la syphilis (RR rajusté 2,5 [95 % IC 1,1 à 5,5) et chez les hommes qui avaient eu une infection aiguë par la syphilis dans les 18 mois précédents (RR rajusté 2,8 [95 % IC 1,0 à 7,9]). Le risque était plus faible chez les hommes qui avaient entrepris un traitement anti-rétroviral (RR rajusté 0,49 [95 % IC 0,25 à 0,95]). L'âge, l'ethnie, la région, la numération des cellules CD4 et la charge virale du VIH n'avaient pas d'effet statistiquement significatif. CONCLUSIONS: D'après ces observations, il serait judicieux de procéder au dépistage périodique du VHC chez les HARSAH positifs au VIH de l'Ontario. De prochaines recherches devraient viser à établir si la syphilis est un simple marqueur de comportements ou de réseaux sexuels à haut risque ou si elle potentialise la transmission sexuelle du VHC chez les personnes atteintes du VIH.

Increasing public support for supervised injection facilities in Ontario, Canada.

AIM: To determine the level and changes in public opinion between 2003 and 2009 among adult Canadians about implementation of supervised injection facilities (SIFs) in Canada. DESIGN: Population-based, telephone survey data collected in 2003 and 2009 were analysed to identify strong, weak, and intermediate support for SIFs. SETTING: Ontario, Canada PARTICIPANTS: Representative samples of adults aged 18 years and over. MEASUREMENTS: Analyses of the agreement with implementation of SIFs in relation to four individual SIF goals and a composite measure. FINDINGS: The final sample sizes for 2003 and 2009 were 1212 and 968, respectively. Between 2003 and 2009, there were increases in the proportion of participants who strongly agreed with implementing SIFs to: reduce neighbourhood problems (0.309 versus 0.556, respectively); increase contact of people who use drugs with health and social workers (0.257 versus 0.479, respectively); reduce overdose deaths or infectious disease among people who use drugs (0.269 versus 0.482, respectively); and encourage safer drug injection (0.213 versus 0.310, respectively). Analyses using a composite measure of agreement across goals showed that 0.776 of participants had mixed opinions about SIFs in 2003, compared with only 0.616 in 2009. There was little change among those who strongly disagreed with all SIF goals (0.091 versus 0.113 in 2003 and 2009, respectively). CONCLUSIONS: Support for implementation of supervised injection facilities in Ontario, Canada increased between 2003 and 2009, but at both time-points a majority still held mixed opinions.

Non-physician clinician provided HIV treatment results in equivalent outcomes as physician-provided care: a meta-analysis.

INTRODUCTION: A severe healthcare worker shortage in sub-Saharan Africa is inhibiting the expansion of HIV treatment. Task shifting, the transfer of antiretroviral therapy (ART) management and initiation from doctors to nurses and other non-physician clinicians, has been proposed to address this problem. However, many health officials remain wary about implementing task shifting policies due to concerns that non-physicians will provide care inferior to physicians. To determine if non-physician-provided HIV care does result in equivalent outcomes to physician-provided care, a meta-analysis was performed. METHODS: Online databases were searched using a predefined strategy. The results for four primary outcomes were combined using a random effects model with sub-groups of non-physician-managed ART and -initiated ART. TB diagnosis rates, adherence, weight gain and patient satisfaction were summarized qualitatively. RESULTS: Mortality (N=59,666) had similar outcomes for non-physicians and physicians, with a hazard ratio of 1.05 (CI: 0.88-1.26). The increase in CD4 levels at one year, as a difference in means of 2.3 (N=17,142, CI: -12.7-17.3), and viral failure at one year, as a risk ratio of 0.89 (N=10,344, CI: 0.65-1.23), were similar for physicians and non-physicians. Interestingly, loss to follow-up (LTFU) (N=53,435) was reduced for non-physicians with a hazard ratio of 0.72 (CI: 0.56-0.94). TB diagnosis rates, adherence and weight gain were similar for non-physicians and physicians. Patient satisfaction appeared higher for non-physicians in qualitative components of studies and was attributed to non-physicians spending more time with patients as well as providing more holistic care. CONCLUSIONS: Non-physician-provided HIV care results in equivalent outcomes to care provided by physicians and may result in decreased LTFU rates.

Patterns of syphilis testing in a large cohort of HIV patients in Ontario, Canada, 2000-2009.

BACKGROUND: Since 2000, reported syphilis cases increased ten-fold in Canada, particularly among men who have sex with men (MSM) co-infected with HIV. We characterized temporal patterns of of syphilis testing in a large cohort of HIV patients in Ontario, Canada. METHODS: We analyzed data from a multi-site cohort of people in HIV care from 2000 to 2009. Data were obtained from medical charts, interviews and record linkage with the syphilis test database at the Public Health Ontario Laboratories. We estimated the proportion that had syphilis testing at least once per year and the period and annual prevalence of reactive tests. RESULTS: Among 4232 participants, the annual proportion tested rose from 2.7% (95%CI 1.9, 3.5) in 2000 to 54.6% (95%CI 52.9, 56.3) in 2009. Testing was most common for participants who were men who have sex with men (MSM), aged <30, recently diagnosed with HIV, were antiretroviral treatment naive, had routine HIV lab testing at least twice in that year, or tested for syphilis in the preceding year. The proportion with at least one reactive test in 2000-09 was 21.0% (95%CI 19.4, 22.7) for MSM, 5.3% (95%CI 3.3, 7.4) for non-MSM males, and 2.6% (95%CI 1.2, 4.0) for women. Among MSM, the annual prevalence of reactive syphilis tests with high RPR titre (≥1:16) peaked at 3.8% in 2009. CONCLUSIONS: The burden of syphilis co-infection rose considerably among HIV-positive MSM, such that by 2009, at least 1 in 5 men had laboratory evidence of current or past infection. Interventions may be needed to boost syphilis testing to achieve goals set by guidelines even in settings with universal health care.

Design considerations for supervised consumption facilities (SCFs): preferences for facilities where people can inject and smoke drugs.

BACKGROUND: Supervised consumption facilities (SCFs) aim to improve the health and well-being of people who use drugs by offering safer and more hygienic alternatives to the risk environments where people typically use drugs in the community. People who smoke crack cocaine may be willing to use supervised smoking facilities (SSFs), but their facility design preferences and the views of other stakeholders have not been previously investigated in detail. METHODS: We consulted with people who use drugs and other stakeholders including police, fire and ambulance service personnel, other city employees and city officials, healthcare providers, residents, and business owners (N = 236) in two Canadian cities without SCFs and asked how facilities ought to be designed. All consultations were audio-recorded and transcribed. Thematic analyses were used to describe the knowledge and opinions of stakeholders. RESULTS: People who use drugs see SSFs as offering public health and safety benefits, while other stakeholders were more sceptical about the need for SSFs. People who use drugs provided insights into how a facility might be designed to accommodate supervised injection and supervised smoking. Their strongest preference would allow both methods of drug use within the same facility with some form of physical separation between the two based on different highs, comfort regarding exposure to different methods of drug administration, and concerns about behaviours often associated with smoking crack cocaine. Other stakeholders raised a number of SSF implementation challenges worthy of consideration. CONCLUSION: Decision-makers in cities considering SCF or SSF implementation should consider the opinions and preferences of potential clients to ensure that facilities will attract, retain, and engage people who use drugs.

Guidelines for better harm reduction: evaluating implementation of best practice recommendations for needle and syringe programs (NSPs).

BACKGROUND: The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations. METHODS: An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document. RESULTS: The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%, n=28) and satellite NSPs (84%, n=52) distributed cookers following the dissemination of the document. All core NSPs (100%, n=32) and nearly all satellite NSPs (97%, n=60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%, n=27) distributed glass stems than the core NSPs (16%, n=5). Commonly cited implementation barriers included funding, senior management and decision-making. CONCLUSION: Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.

A human immunodeficiency virus risk reduction intervention for incarcerated youth: a randomized controlled trial.

PURPOSE: To evaluate, by gender, the impact of a structured, comprehensive risk reduction intervention with and without boosters on human immunodeficiency virus (HIV) knowledge, attitudes and behaviors in incarcerated youth; and to determine predictors of increasing HIV knowledge and reducing high-risk attitudes and behaviors. METHODS: This randomized controlled trial involved participants completing structured interviews at 1, 3, and 6 months. Repeated measures analysis of variance was used to analyze changes over time. The study was conducted in secure custody facilities and in the community. The study sample comprising 391 incarcerated youth, 102 female and 289 male aged 12-18, formed the voluntary sample. Participants were randomly assigned to one of three conditions: education intervention; education intervention with booster; or no systematic intervention. The outcome and predictor measures included the Rosenberg Self-Esteem Scale, Youth Self Report, Drug Use Inventory, and HIV Knowledge, Attitudes and Behavior Scale. RESULTS: The 6-month retention rate was 59.6%. At 6 months, males in the education and booster groups sustained increases in knowledge scores (p < 0.001). Females in these groups sustained increased condom attitude scores (p = 0.004). Males in the booster group sustained increased prevention attitude scores (p = 0.017). Females in the booster group reported more consistent condom use (odds ratio [OR] = 4.20; 95% confidence interval [CI] = 1.81, 9.77). Age, gender, drug use, and psychological profiles were predictive of outcome. CONCLUSIONS: The intervention and boosters led to gender-specific improvements in knowledge, attitudes, and condom use. Result variations by gender underline the importance of gender issues in prevention interventions. Predictors of success were identified to inform future HIV education interventions.

Preventing HIV transmission among Iranian prisoners: initial support for providing education on the benefits of harm reduction practices.

BACKGROUND: Harm reduction is a health-centred approach that seeks to reduce the health and social harms associated with high-risk behaviors, such as illicit drug use. The objective of this study is to determine the association between the beliefs of a group of adult, male prisoners in Iran about the transmission of HIV and their high-risk practices while in prison. METHODS: A cross-sectional study was conducted in 2004. The study population was a random selection of 100 men incarcerated at Rajaei-Shahr prison. The data were collected through a self-administered questionnaire. Focus group discussions were held at the prison to guide the design of the questionnaire. The relationship between components of the Health Belief Model (HBM) and prisoners' risky HIV-related behaviors was examined. RESULTS: Calculating Pearson's correlation coefficient, a significant, positive association was found between the benefit component of the HBM and prisoners not engaging in HIV high-risk behaviors. CONCLUSION: Educational harm reduction initiatives that promote the effectiveness of strategies designed to reduce the risk of HIV transmission may decrease prisoners' high-risk behaviors. This finding provides initial support for the Iran prison system's current offering of HIV/AIDS harm reduction programming and suggests the need to offer increased education about the effectiveness of HIV prevention practices.

Vaccine immunogenicity in injecting drug users: a systematic review.

Injection drug use is a prevalent global phenomenon; one not bound by a country's level of development or geographical location. Injection drug users (IDUs) are at high risk for a variety of parenterally acquired and transmitted infections. Licensed vaccines are available for some of these infectious diseases, such as tetanus, influenza, and hepatitis A and B viruses; however, there have been conflicting reports as to their immunogenicity in IDUs. We summarise the lessons learned from studies evaluating the immunogenicity of vaccination strategies in IDUs. A common theme across these diseases is that although there is a tendency towards decreased antibody responses after immunisation, there is no conclusive evidence linking these observations to a decrease in clinical protection from infection. There is a clear need for definitive studies of vaccination strategies in IDUs; however, a synthesis of the available published evidence suggests that immunisation does result in effective clinical protection from disease in this population. The inclusion of IDUs as a high-risk study population in future trials evaluating HIV and hepatitis C virus vaccines will help to assess the immunogenicity of candidate vaccines against parenteral exposure, and also to evaluate the efficacy of candidates as promising antigens become available.

Reduction in injection-related HIV risk after 6 months in a low-threshold methadone treatment program.

This study assessed injection-related HIV risk behavioral changes among opioid users 6 months after enrollment in low-threshold (harm reduction based) metha-done maintenance treatment (MMT) programs within needle exchange services in Kingston and Toronto, Ontario, Canada. Changes were assessed for all participants (whole cohort), participants who continued to use illicit drugs by any route (drug-using subcohort); and those who continued to inject drugs (injecting subcohort). In this prospective observational cohort study, an interviewer-administered questionnaire examining injection-related HIV risk behaviors was administered to 183 study participants at entry to treatment and 6 months later. Changes in risk behaviors were analyzed using conditional logistic regression which took into account the paired nature of the data. We found that the proportion of participants injecting drugs, sharing needles, sharing drug equipment, indirectly sharing and using shooting galleries declined with follow-up for the whole cohort. Within the drug-using subcohort, there was a decrease in the proportion of individuals who injected drugs, while within the injecting subcohort the sharing of injection equipment and the use of shooting galleries declined. Our findings suggest that low-threshold MMT programs can reduce the risk of HIV without the enforcement of abstinence-based policies.

Trends in HIV-1 in young adults in south India from 2000 to 2004: a prevalence study.

BACKGROUND: Major increases in HIV-1 prevalence in India have been predicted. Incident infections need to be tracked to understand the epidemic's course, especially in some southern states of India where the epidemic is more advanced. To estimate incidence, we investigated the prevalence of HIV-1 in young people attending antenatal and sexually transmitted infection (STI) clinics in India. METHODS: We analysed unlinked, anonymous HIV-1 prevalence data from 294 050 women attending 216 antenatal clinics and 58 790 men attending 132 STI clinics in 2000-04. Southern and northern states were analysed separately. FINDINGS: The age-standardised HIV-1 prevalence in women aged 15-24 years in southern states fell from 1.7% to 1.1% in 2000-04 (relative reduction 35%; p(trend)<0.0001, yearly reduction 11%), but did not fall significantly in women aged 25-34 years. Reductions in women aged 15-24 years were seen in key demographic groups and were similar in sites tested continuously or in all sites. Prevalence in the north was about a fifth of that in the south, with no significant decreases (or increases) in 2000-04. Prevalence fell in men aged 20-29 years attending STI clinics in the south (p(trend)<0.0001), including those with ulcerative STIs (p(trend)=0.0008), but reductions were more modest in their northern counterparts. INTERPRETATION: A reduction of more than a third in HIV-1 prevalence in 2000-04 in young women in south India seems realistic, and is not easily attributable to bias or to mortality. This fall is probably due to rising condom use by men and female sex workers in south India, and thus reduced transmission to wives. Expansion of peer-based condom and education programmes for sex workers remains a top priority to control HIV-1 in India.

Determinants of health-related quality of life of opiate users at entry to low-threshold methadone programs.

OBJECTIVE: The aim of this study was to conduct an exploratory analysis of factors associated with poor health-related quality of life (HRQOL) among opiate users at entry to low-threshold methadone treatment. METHODS: The SF-36 questionnaire was administered to 145 opiate users at enrollment into low-threshold methadone maintenance programs. ANOVA and correlational analyses were performed to investigate the determinants of poor physical and mental composite summary scales (PCS and MCS) of the SF-36 among opiate users. Stepwise regression methods were also employed to fit PCS and MCS multivariate models. RESULTS: Age, employment status, chronic medical conditions, hospitalization, emotional abuse, sexual abuse and age at first injection episode were significantly associated with PCS. Mental health problems, sexual abuse, physical abuse, the use of sedatives, the use of cocaine, the number of days of cocaine use, sedative use and multiple substance use in the past month were significantly associated with MCS. The variances in the MCS and PCS were not readily explained by any one factor. CONCLUSION: The multiplicity of factors influencing HRQOL of opiate users suggests the need for a range of services within the context of a methadone program, addressing primary medical care needs as well as treatment for both mental health problems and abuse issues.

Nonfinancial factors associated with decreased plasma viral load testing in Ontario, Canada.

OBJECTIVE: To examine whether individual characteristics were associated with differential use of viral load testing when testing is available without charge to all HIV-positive patients with provincial health insurance. METHODS: Individuals enrolled in the HIV Ontario Observational Database with complete medication records and health insurance numbers for linkage were studied. Generalized estimating equation regression models were used to examine the relationship between time-varying covariates such as plasma viral load levels, CD4 counts, and antiretroviral regimen characteristics and the number of days between viral load tests and the occurrence of an interval of >or=6 or 9 months between tests. RESULTS: A total of 1032 individuals were included in the analysis with a median follow-up of 4.6 years and a median of 18 viral load tests. In multivariate analyses, clinically important gaps in viral load testing were more likely among injection drug users (odds ratio [OR]=1.86, P<0.0001), in more recent years (P<0.01) and for individuals not using antiretrovirals (OR=1.70, P<0.0001) and less likely among individuals using >4 antiretrovirals (OR=0.62, P<0.0001). Results were similar when the outcome was the number of days between tests. CONCLUSIONS: Injection drug users, younger individuals, and residents of Toronto used fewer viral load tests than other individuals, even when financial barriers to testing were removed.

Self-perceived health among Canadian opiate users: a comparison to the general population and to other chronic disease populations.

BACKGROUND: There are an estimated 40,000 to 90,000 injection opiate users in Canada. The social, economic and health consequences of opiate addiction have been well documented. However, there are no data on the self-perceived health status of opiate users in Canada. Therefore, the goal of this research is to gain an understanding of the self-perceived health status of opiate users by comparing the health-related quality of life of opiate users to chronic disease populations and to the general population. METHODS: The SF-36 was administered to a nonrandom sample of 143 opiate users entering low-threshold methadone treatment. Two sample t-tests were performed to assess statistical differences, at a 5% level of significance, between population scores across SF-36 dimensions. RESULTS: Opiate users perceived both their mental and physical health as worse than the general population and individuals with minor and serious medical problems, but comparable to those with diagnosed psychiatric illnesses. CONCLUSIONS: Methadone treatment services should incorporate both primary care and psychiatric care into their programs, or at the very least secure appropriate referral mechanisms to ancillary services to ensure that the health concerns of opiate users are dealt with in the context of their treatment program.

Regional variation in HIV prevalence and risk behaviours in Ontario injection drug users (IDU).

OBJECTIVES: To measure HIV prevalence, risk behaviours, and further service needs in needle exchange programs throughout Ontario, and to conduct regional comparisons. METHODS: Injection drug users (IDU) recruited through the efforts of needle exchange programme (NEP) staff in 9 Ontario cities during 1997-98 completed questionnaires about their drug use and behaviours and provided saliva and/or dried blood samples for anonymous unlinked HIV testing. RESULTS: Demographic and drug use characteristics of participants showed great regional variation. HIV prevalence by region ranged from 1.4% to 14.7%. In addition to region, HIV positivity was associated with injecting for more than 5 years, use of (powder) cocaine, use of crack, binge injection (10 or more times per day at least once in the previous 6 months), and being a longer-term NEP user. Sharing of injection equipment, and especially of other drug injection materials such as water and cookers, remain important issues, although much of the sharing reported is with only one other person. Unmet demand for methadone treatment was identified despite changes in regulation of methadone provision designed to make it more accessible. CONCLUSIONS: This study suggested significant further HIV prevention needs among IDU throughout Ontario. There is also evidence of potential to provide additional services such as methadone at NEPs if the required resources are invested. NEPs that have succeeded in gaining the trust of high-risk IDU offer a means to provide access to needed services.

Increases in HIV incidence among men who have sex with men undergoing repeat diagnostic HIV testing in Ontario, Canada.

OBJECTIVE: To estimate HIV incidence density for different exposure categories among people undergoing repeat testing in Ontario, Canada. METHODS: Persons using voluntary, diagnostic HIV testing at least twice were identified by computerized and manual record linkage. In the 1992-2000 period, 980 seroconverters and 340 994 repeat negative testers contributed 936 145 person years (PY) of observation. Incidence density (ID) was calculated according to Kitayaporn et al. Poisson regression was used to evaluate differences in incidence. RESULTS: Among men who have sex with men (MSM), ID declined between 1992-1996, from 1.23 per 100 PY in 1992 to 0.79 per 100 PY in 1996 [relative risk (RR), 0.86 per year; 95% confidence interval (CI), 0.77-0.96]. Subsequently, ID increased to 1.39 per 100 PY in 1999 (RR, 1.18 per year; 95% CI, 1.05-1.34). In 2000, ID was 1.16 per 100 PY but this decrease was not statistically significantly different from 1999. MSM in their twenties had the highest ID in 1992-1996, but in 1996-2000 MSM in their thirties had the highest risk of infection. Among injecting drug users (IDU), ID decreased from 0.64 per 100 PY in 1992 to 0.14 per 100 PY in 2000 (RR, 0.87 per year; 95% CI, 0.80-0.94). Among heterosexuals, annual incidence remained constant at about 0.03 per 100 PY in 1992-2000. CONCLUSIONS: Increases in ID were identified among MSM from 1996 to 1999. These findings are consistent with other research. Continued vigilance and improved surveillance are needed to better understand and control the epidemic.