The Cedar Project: Racism and its impacts on health and wellbeing among young Indigenous people who use drugs in Prince George and Vancouver, BC.

Racism continues to drive health disparities between Indigenous and non-Indigenous peoples in Canada. This study focuses on racism experienced by young Indigenous people who have used drugs in British Columbia (BC), and predictors of interpersonal racism. Cedar Project is a community-governed cohort study involving young Indigenous people who use drugs in Vancouver and Prince George, BC. This cross-sectional study included data collected between August 2015-October 2016. The Measure of Indigenous Racism Experiences (MIRE) scale was used to assess experiences of interpersonal racism across 9 unique settings on a 5-point Likert scale, collapsing responses into three categories (none/low/high). Multinomial logistic regression models were used to examine associations between key variables and interpersonal racism. Among 321 participants, 79% (n = 255) experienced racism in at least one setting. Thirty two percent (n = 102) experienced high interpersonal racism from police, governmental agencies (child 'welfare', health personnel), and in public settings. Ever having a child apprehended (AOR:2.76, 95%CI:1.14-6.65), probable post-traumatic stress (AOR:2.64; 95%CI:1.08-6.46), trying to quit substances (AOR:3.69; 95%CI:1.04-13.06), leaving emergency room without receiving treatment (AOR:3.05; 95%CI:1.22-7.64), and having a traditional language spoken at home while growing up (AOR:2.86; 95%CI:1.90-6.90) were associated with high interpersonal racism. Among women, experiencing high interpersonal racism was more likely if they lived in Prince George (AOR:3.94; 95%CI:1.07-14.50), ever had a child apprehended (AOR:5.09; 95%CI:1.50-17.30), and had probable post-traumatic stress (AOR:5.21; 95%CI:1.43-18.95). Addressing racism experienced by Indigenous peoples requires immediate structural systemic, and interpersonal anti-racist reforms.

Cango Lyec (Healing the Elephant): HIV Prevalence and Vulnerabilities Among Adolescent Girls and Young Women in Postconflict Northern Uganda.

OBJECTIVES: Adolescent girls and young women younger than 25 years (AGYW) account for disproportionate HIV infections in sub-Saharan Africa. Impacts of war in Northern Uganda continue to affect HIV-related health and wellbeing of young people postconflict. Prevalence and incidence of HIV infection were estimated, and factors associated with HIV prevalence among sexually active AGYW in Northern Uganda were investigated. METHODS: Cango Lyec is a cohort involving conflict-affected populations in Northern Uganda. Nine randomly selected communities in Gulu, Nwoya, and Amuru districts were mapped. House-to-house census was conducted. Consenting participants aged 13-49 years were enrolled over 3 study rounds (2011-2015), of whom 533 were AGYW and had ever had sex. Data were collected on trauma, depression, and sociodemographic-behavioral characteristics. Venous blood was taken for HIV and syphilis serology. Multivariable logistic regression determined baseline factors associated with HIV prevalence. RESULTS: HIV prevalence among AGYW was 9.7% (95% CI: 7.3 to 12.6). AGYW living in Gulu (adjusted risk ratio, aRR: 2.48; 95% CI: 1.12 to 5.51) or Nwoya (aRR: 2.65; 95% CI: 1.03 to 6.83) were more likely than in Amuru to be living with HIV. Having self-reported genital ulcers (aRR: 1.93; 95% CI: 0.97 to 3.85) or active syphilis (aRR: 3.79; 95% CI: 2.35 to 6.12) was associated with increased risk of HIV infection. The likelihood of HIV was higher for those who experienced sexual violence in the context of war (aRR: 2.37; 95% CI: 1.21 to 4.62) and/or probable depression (aRR: 1.95; 95% CI: 1.08 to 3.54). HIV incidence was 8.9 per 1000 person-years. CONCLUSION: Ongoing legacies of war, especially gender violence and trauma, contribute to HIV vulnerability among sexually active AGYW. Wholistic approaches integrating HIV prevention with culturally safe initiatives promoting sexual and mental health in Northern Uganda are essential.

Overcoming the soul wound: Reflecting on experiences and resilience of intergenerational residential school survivors.

BACKGROUND: Between 1883 and 1996, thousands of Indigenous children were apprehended into Canada's Residential School System. Survivors and their descendants have testified to genocidal harms caused across generations. Yet, Indigenous Peoples continue to exist and resist through inherent resilience described by intergenerational survivors in this paper. OBJECTIVE: This article focuses on stories demonstrating the strength, power, and resilience of intergenerational residential school survivors. PARTICIPANTS & SETTING: Cedar Project is an Indigenous-led cohort study that began as a HIV/AIDS response and contributes to healing among young Indigenous people who use drugs in British Columbia, Canada. It is governed by the Cedar Project Partnership, an Indigenous body of Elders, leaders, and health/social services experts. METHODS: We present qualitative research involving in-depth interviews carried out with Cedar participants who have experienced significant and complex adversities including childhood maltreatment and illicit drug use. Woven throughout, Indigenous scholars who are themselves intergenerational (children and grandchildren) of residential school survivors provide first-person reflections on the findings. RESULTS: Analysis focused on narratives of resilience and resistance to stresses of intergenerational traumas across three broad themes: working to break cycles of intergenerational trauma; foundations of resilience and making positive changes and; hopes and dreams. CONCLUSIONS: Findings establish deeper understanding of processes that enable young people to cope with stresses of intergenerational traumas while facing institutional and structural barriers to wellness. Reflections provide context about how intergenerational experiences intersect with challenges that young intergenerational survivors continue to face. We highlight pathways to healing and sources of strength that inform recommendations for wellness.

Cango Lyec (Healing the Elephant): Probable post-traumatic stress disorder (PTSD) and depression in Northern Uganda five years after a violent conflict.

Background: From 1986 to 2006, Northern Uganda experienced an atrocious civil war between the Lord's Resistance Army (LRA) and the Ugandan government. Acholi people living in the region continue to be impacted by trauma sequelae of the war and a wide range of daily stressors including poverty, hunger, and high rates of HIV infection. To date, there is a dearth of gender-differentiated mental health research in this post-conflict setting. The current study aimed to estimate the prevalence of probable post-traumatic stress disorder (PTSD) and depression in three districts most affected by the Northern Ugandan conflict and examine socio-structural, war-related, and sexual vulnerability factors associated with mental health. Methods: Cango Lyec (Healing the Elephant) is an open cohort study involving participants from eight randomly selected communities in Amuru, Gulu, and Nwoya districts of Northern Uganda. Between November 2011 and July 2012, the baseline cohort (N = 2,458) completed the Harvard Trauma Questionnaire (HTQ) and Hopkins Symptom Checklist-25 (HSCL-25) for screening PTSD and depression, in addition to a detailed questionnaire assessing socio-demographic-behavioral characteristics. Baseline categorical variables were compared between males and females using Fisher's exact test. Multivariate logistic regression was used to model correlates of probable PTSD and depression. All analyses were stratified by gender. Results: The overall prevalence of probable PTSD and depression was 11.7% and 15.2% respectively. Among former abductees, the prevalence was 23.2% for probable PTSD and 26.6% for probable depression. Women were significantly more likely to experience mental distress than men. Factors associated with mental distress included wartime trauma (adjusted odds ratios ranging from 2.80 to 7.19), experiences of abduction (adjusted odds ratios ranging from 1.97 to 3.03), and lack of housing stability and safety (adjusted odds ratios ranging from 1.95 to 4.59). Additional risk factors for women included HIV infection (AOR=1.90; 95% CI: 1.29-2.80), sexual abuse in the context of war (AOR=1.58; 95% CI: 1.02-2.45), and intimate partner violence (AOR=2.45; 95% CI: 1.07-5.63). Conclusion: Cango Lyec participants displayed lower than previously reported yet significant levels of probable PTSD and depression. Based on findings from this study, providing trauma-informed care, ensuring food and housing security, eliminating gender-based violence, and reintegrating former abductees remain important tasks to facilitate post-conflict rehabilitation in Northern Uganda.

The Cedar Project: exploring the role of colonial harms and childhood maltreatment on HIV and hepatitis C infection in a cohort study involving young Indigenous people who use drugs in two Canadian cities.

OBJECTIVES: This study examined associations between childhood maltreatment, colonial harms and sex/drug-related risks for HIV and hepatitis C virus (HCV) infection among young Indigenous people who use drugs. DESIGN: The Cedar Project is a cohort involving young Indigenous people who use drugs in British Columbia (BC), Canada. Indigenous collaborators, collectively known as the Cedar Project Partnership, govern the entire research process. SETTING: Vancouver is a large city on the traditional territory of the Coast Salish peoples. Prince George is a mid-sized city, on the traditional territory of Lheidli T'enneh First Nation. PARTICIPANTS: 420 participants completed the Childhood Trauma Questionnaire and returned for follow-up from 2003 to 2016. PRIMARY/SECONDARY OUTCOME MEASURES: Primary outcomes were HIV and HCV infection over the study period. Secondary outcomes included sex and substance use-related risks. RESULTS: Prevalence of childhood maltreatment was 92.6% experienced any maltreatment; 73.4% experienced emotional abuse; 62.6% experienced physical abuse; 60.3% experienced sexual abuse; 69.5% experienced emotional neglect and 79.1% experienced physical neglect. We observed significant associations between childhood maltreatment and apprehensions into residential schools and foster care. All maltreatment types were associated with higher odds of sex/substance use-related risks; sexual abuse was associated with higher odds of HCV infection (adjusted OR: 1.67; 95% CI 1.05 to 2.66; p=0.031). CONCLUSIONS: Findings reflect high prevalence of childhood maltreatment and their associations with HIV/HCV risk and HCV infection. Public health prevention and treatment initiatives must be trauma informed and culturally safe to support healing, health, and well-being.

The Cedar Project: Relationship between child apprehension and attempted suicide among young Indigenous mothers impacted by substance use in two Canadian cities.

Indigenous leaders are gravely concerned over disproportionate representation of Indigenous children in Canada's child welfare systems. Forced separation from children is deeply traumatizing for mothers and detrimental to the wellbeing of Indigenous families, communities and Nations. This study examined relationships between child apprehension and suicide attempt within a cohort of young Indigenous women impacted by substance use. We utilized data collected every 6 months (2008-2016) by the Cedar Project, an Indigenous-governed cohort study involving young Indigenous people who use drugs in British Columbia, Canada. Recent child apprehension was defined as having a child apprehended by the Ministry of Child and Family Development since last visit. Recurrent event Cox proportional hazards models estimated the independent effect of child apprehension on maternal suicide attempt. Among 293 participants, 78 (27%) reported 136 child apprehensions; incidence of first apprehension was 6.64 (95%CI: 5.25-8.29) per 100 person-years. Forty-seven (16%) participants reported 75 suicide attempts with an incidence of 4.00 (95%CI: 2.94-5.33) per 100 person-years. Participants who reported recent child apprehension (HR: 1.88, 95%CI: 1.00-3.55), had a parent attend residential school (HR: 4.12, 95%CI: 1.63-10.46), experienced recent sexual assault (HR: 4.04, 95%CI: 2.04-7.99), violence (HR: 2.54, 95%CI: 1.52-4.27) or overdose (HR: 4.97, 95%CI: 2.96-8.35) were more likely to attempt suicide. Participants who had a traditional language spoken in the home growing up were half as likely to attempt suicide (HR: 0.49, 95%CI: 0.23-1.01). Results suggest that child welfare systems in Canada perpetuate historical and intergenerational trauma among young Indigenous mothers. Indigenous self-determination over child welfare and culturally safe services are urgently needed to end cycles of child apprehension and support the wellbeing of families, communities and Nations.

Cango Lyec (Healing the Elephant): Chronic Hepatitis B Virus among post-conflict affected populations living in mid-Northern Uganda.

BACKGROUND: The legacy of war in Northern Uganda continues to impact people's health and wellbeing in the Acholi region. Despite increasing attention to Hepatitis B Virus (HBV) in Uganda and globally, concerns remain that unique drivers of infection, and barriers to screening, and treatment, persist among those affected by conflict. METHODS: Cango Lyec (Healing the Elephant) cohort survey involved conflict-affected adults aged 13-49 in three mid-Northern Uganda districts (Gulu, Amuru and Nwoya). Baseline (2011-2012) samples were tested for HBV surface antigen (HBsAg), HBV e-antigen (HBeAg), antibodies to HBV surface antigen (HBsAb), antibodies to HBV e-antigen (HBeAb), and antibodies to HBV core antigen (HBcAb). All HBsAg positive samples were tested for IgM antibodies to HBV B core antigen (HBc-IgM) and where available, >6-month follow-up samples were tested for HBeAg and HBV DNA. Data were analyzed using STATA 15 software. Logistic regression accounted for variance due to complex two-stage sampling that included stratification, unequal selection probabilities and community clustering. Odds ratios measured effect potential risk factors associated with chronic HBV infection. RESULTS: Among 2,421 participants, 45.7% were still susceptible to HBV infection. HBsAg seropositivity was 11.9% (10.9-13.0), chronic HBV was 11.6% (10.4-12.8), acquired immunity resulting from vaccination was 10.9%, and prior natural infection was 31.5%. Older age (OR:0.570; 95%CI:0.368-0.883) and higher education (OR:0.598; 95%CI:0.412-0.868) were associated with reduced odds of chronic HBV infection. Being male (OR:1.639; 95%CI:1.007-2.669) and having been abducted (OR:1.461; 95%CI:1.055-2.023) were associated with increased odds of infection. Among women, having 1 or 2 pregnancies (compared to none or >2) was associated with increased odds of infection (OR:1.764; 95%CI:1.009-3.084). CONCLUSION: Chronic HBV is endemic in Gulu, Amuru and Nwoya districts. Recommended strategies to reduce post-conflict prevalence include establishment of Northern Uganda Liver Wellness Centres, integration of screening and treatment into antenatal care, and roll out of birth-dose vaccination.

The Cedar Project: Historical, structural and interpersonal determinants of involvement in survival sex work over time among Indigenous women who have used drugs in two Canadian cities.

BACKGROUND: Indigenous women involved in survival sex work face multiple layers of discrimination, criminalization and alarming levels of intergenerational and lifetime trauma. This longitudinal study examined historical, structural and interpersonal factors associated with survival sex work involvement among Indigenous women who have used drugs in British Columbia (BC), Canada. METHODS: The Cedar Project is an ongoing cohort study involving young Indigenous people who have used illicit drugs in Vancouver and Prince George, BC. Data was collected every 6 months from 2007 to 2016 . Generalized linear mixed-effects modeling was used to model survival sex work involvement, defined as exchanging sex for money, drugs, food or shelter in the previous six months. RESULTS: Among 292 participants, 34% reported their family always/often lived by traditional culture and 37% reported their family always/often spoke their traditional language. In contrast, 48% had a parent in residential school and 72% were removed from their biological parents. In total, 55% of women were involved in survival sex work at baseline. In adjusted analyses, those who were single (ARR: 1.91; 95% CI: 1.50-2.35), identified as two-spirit (ARR: 2.16; 95% CI: 1.36-2.91), experienced sexual assault (ARR: 1.90; 95% CI: 1.22-2.58), were denied access to shelter (ARR: 1.71; 95% CI: 1.18-2.28), used crack daily (ARR: 2.85; 95% CI: 2.36-3.31), used injection drugs (ARR: 2.52; 95% CI: 1.98-3.07), and were unable to access substance use treatment (ARR: 1.58; 95% CI: 1.15-2.05) were more likely to be involved in sex work. CONCLUSION: Indigenous-governed, wellness-based harm-reduction interventions, and structural reforms addressing housing insecurity and normalization of a culture of violence against Indigenous women, especially those involved in survival sex work, are urgently needed in Canada.

The Cedar Project - Mobile Phone Use and Acceptability of Mobile Health Among Young Indigenous People Who Have Used Drugs in British Columbia, Canada: Mixed Methods Exploratory Study.

BACKGROUND: Indigenous leaders continue to be concerned about high rates of HIV and barriers to HIV treatment among young Indigenous people involved in substance use. Growing evidence suggests that using mobile phones for health (mHealth) may be a powerful way to support connection with health services, including HIV prevention and treatment. OBJECTIVE: This study examined the patterns of mobile phone ownership and use among young Indigenous people who have used drugs living with or vulnerable to HIV and explored the acceptability of mHealth to support access to health care in this population. METHODS: The Cedar Project is a cohort study involving young Indigenous people who have used drugs in Vancouver and Prince George, British Columbia. This mixed methods exploratory study involved 131 Cedar Project participants enrolled in our WelTel mHealth program. At enrollment, participants completed a questionnaire related to mobile phone use and interest in mHealth. Data were linked to Cedar Project questionnaires and serodata. We present comparative statistics (quantitative) and results of a rapid thematic analysis (qualitative) related to mobile phone patterns and interest in receiving mHealth. RESULTS: Less than half of the participants (59/130; 45.4%) reported owning a phone. Among those with a phone, the majority owned a smartphone (46/59; 78%). Most participants with a phone reported having an unlimited texting plan (39/55; 71%), using the internet on their phone (44/59; 75%), and texting daily (44/55; 80%). A majority reported that using a mobile phone for health would be invaluable (120/130; 92.3%). There were no differences in mHealth acceptance between participants who owned a phone and those who did not (P>.99). All but one participant living with HIV felt using a mobile phone would be helpful for their health, while a small proportion of HIV-negative participants remained unsure (1.9% vs 11.7%; P=.047). In response to open-ended questions asking why using a mobile phone may be helpful for health, participants identified a diverse set of anticipated benefits: (1) connection for emotional, mental, and spiritual support, (2) connection to family, (3) staying in touch and/or being reachable, (4) overcoming current barriers to phone use, (5) convenience, privacy, and safety, and (6) access to health care and emergency services. CONCLUSIONS: We observed high acceptance and interest in using mobile phone technology for health despite low rates of personal mobile phone connectivity among young Indigenous people who have used drugs living with and vulnerable to HIV in British Columbia, Canada. Mobile phones were viewed as a way to support connections and relationships that are seen as critical to health and well-being among young Indigenous people in this study. Findings may be useful for health care providers preparing to scale up mHealth programs to support HIV prevention and treatment in this population.

Cango Lyec (Healing the Elephant): HIV incidence in post-conflict Northern Uganda.

BACKGROUND: Civil war in Northern Uganda resulted in widespread atrocities, human rights violations, and death, and caused millions to flee to internally displaced persons camps. War-related traumas combined with difficulties accessing HIV prevention and health services has led to extreme HIV-related vulnerability among conflict-affected people who survived the war. Objectives were to (1) determine HIV incidence among conflict-affected people in Northern Uganda and (2) identify vulnerabilities associated with HIV infection. METHODS: The Cango Lyec (Healing the Elephant) Project is a prospective cohort involving conflict-affected populations in three districts in Northern Uganda. In 2011, eight randomly selected communities were mapped, and a census was conducted. Consenting participants aged 13-49 years were followed over three rounds of follow-up. Longitudinal data collected included war-related experiences, sexual vulnerabilities, and sociodemographics. Blood samples were tested for HIV-1 at baseline and each 12-month follow-up. Multivariable Cox proportional hazard models determined factors associated with HIV incidence. FINDINGS: Overall, 1920 baseline HIV-negative participants with at least one follow-up contributed 3877 person-years (py) for analysis. Thirty-nine (23 female, 16 male) participants contracted HIV during follow-up. Age- and gender-standardised HIV incidence rate was 10•2 per 1000py (95%CI: 7•2-14•0). Stratified by sex, the age-adjusted HIV incidence was 11•0 per 1000py (95%CI: 6•9-16•6) among women and 9•4 per 1000py (95%CI: 5•3-15•3) among men. Adjusting for confounders, factors associated with risk of HIV included: having been abducted (HR: 3•70; 95%CI: 1•87-7•34), experiencing ≥12 war-related traumatic events (HR: 2•91 95%CI: 1•28-6•60), suicide ideation (HR: 2•83; 95%CI: 1•00-8•03), having ≥2 sexual partners (HR: 4•68; 95%CI: 1•36-16•05), inconsistent condom use (HR: 6•75; 95%CI: 2•49-18•29), and self-reported genital ulcers (HR: 4•39; 95%CI: 2•04-9•45). INTERPRETATION: Conflict-affected participants who had experienced abduction and multiple traumas during the war were at greater risk of HIV infection. Trauma-informed HIV prevention and treatment services, and culturally-safe mental health initiatives, are urgent for Northern Uganda.

Experiences of the HIV Cascade of Care Among Indigenous Peoples: A Systematic Review.

Indigenous leaders remain concerned that systemic oppression and culturally unsafe care impede Indigenous peoples living with HIV from accessing health services that make up the HIV cascade of care. We conducted a systematic review to assess the evidence related to experiences of the HIV care cascade among Indigenous peoples in Australia, Canada, New Zealand, and United States. We identified 93 qualitative and quantitative articles published between 1996 and 2017 reporting primary data on cascade outcomes disaggregated by Indigenous identity. Twelve involved data from Australia, 52 from Canada, 3 from New Zealand and 26 from United States. The majority dealt with HIV testing/diagnosis (50). Relatively few addressed post-diagnosis experiences: linkage (14); retention (20); treatment initiation (21); adherence (23); and viral suppression (24). With the HIV cascade of care increasingly the focus of global, national, and local HIV agendas, it is critical that culturally-safe care for Indigenous peoples is available at all stages.

Cango Lyec (Healing the Elephant): Gender Differences in HIV Infection in Post-conflict Northern Uganda.

BACKGROUND: As previously encamped resettle, potential for rapid HIV transmission in post-conflict Northern Uganda is concerning. Women in particular may be experiencing heightened vulnerability resulting from war-related sexual violence. SETTING: Cango Lyec (Healing the Elephant) Project is a cohort involving conflict-affected people in 3 districts in Northern Uganda. METHODS: Eight randomly selected communities were mapped, and a census was conducted. Participants aged 13-49 years completed questionnaires in Luo on war-related experiences, mental health, sexual vulnerabilities, and sociodemographics. Blood samples were tested for HIV and syphilis. Baseline data from all sexually active participants was used to determine gender differences in HIV prevalence. Multivariate modeling determined correlates of HIV by gender. RESULTS: Among 2008 participants, HIV prevalence was higher among women [17.2; 95% confidence interval (CI): 14.7 to 19.7] compared to men (10.6; 95% CI: 8.0 to 13.2, <0.001). Among women, correlates of HIV included: war-related sexual assault [adjusted odds ratio (AOR): 1.95; 95% CI: 1.16 to 3.26]; probable depression (AOR: 2.22; 95% CI: 1.46 to 3.37); probable post-traumatic stress disorder (AOR: 2.03; 95% CI: 1.45 to 2.84); experiencing ≥12 traumatic events (AOR: 2.04; 95% CI: 1.31 to 3.18); suicide ideation (AOR: 1.67; 95% CI: 1.22 to 2.28); living in a female-headed household (AOR: 2.76; 95% CI: 1.70 to 4.49); first sexual partner ≥10 years older (AOR: 1.69; 95% CI: 1.07 to 2.67); sex for exchange (AOR: 5.51; 95% CI: 1.76 to 17.31); having 2 (AOR: 2.54; 95% CI: 1.23 to 5.23) or 3+ (AOR: 4.65; 95% CI: 2.65 to 8.18) sexual partners; inconsistent condom use (AOR: 0.40; 95% CI: 0.29 to 0.57); genital ulcers (AOR: 3.08; 95% CI: 2.16 to 4.38); active syphilis (AOR: 4.33; 95% CI: 1.22 to 15.40); and ill health without medical care (AOR: 2.02; 95% CI: 1.22 to 3.34). Among men, correlates of HIV included no condom at sexual debut (AOR: 1.92; 95% CI: 1.30 to 2.83) and genital ulcers (AOR: 4.40; 95% CI: 1.35 to 14.40). CONCLUSION: Women are disproportionately impacted by HIV, trauma, and depression in this conflict-affected population. Trauma-informed HIV prevention and culturally safe mental health initiatives are urgently required.

Ethnicity and HIV vulnerabilities among men who have sex with men in China.

Ethnic affiliation can define sociocultural boundaries and contribute to the HIV vulnerabilities faced by men who have sex with men (MSM). This study investigated the influence of ethnic affiliation on HIV vulnerabilities among MSM in North China. Our study analyzed a cross-sectional survey of MSM (n = 398) in two major North China cities. We examined associations between ethnic affiliation and (a) HIV status, (b) sexual behaviors and experiences, and (c) substance use. Compared to ethnic majority Han MSM: MSM belonging to ethnic minority groups of South China had significantly greater odds of HIV infection (AOR: 7.40; 95% CI: 2.33-23.47) and experience of forced sex (AOR: 3.27; 95% CI: 1.12-9.52). Compared to ethnic majority Han MSM, Ethnic Hui MSM had significantly lower odds of condomless anal sex (AOR: 0.41; 95% CI: 0.21-0.82) and significantly greater odds of circumcision (AOR: 2.62; 95% CI: 1.24-5.51). HIV prevalence and riskier sexual behaviors among MSM in China appear to vary significantly by ethnic affiliation. Current epidemiological practices of aggregating all ethnic minority groups in China into a single category may be masking important interethnic differences in HIV risk, and precluding opportunities for more culturally appropriate interventions.

Correction to: The Cedar Project: Using Indigenous-specific determinants of health to predict substance use among young pregnant-involved Indigenous women in Canada.

After publication of the original article (1) it was noted that the title of this manuscript was incorrect. The title presently reads "The cedar project: using indigenous-specific determinants of health to predict substance use among young pregnant-involved aboriginal women" but should read "The Cedar Project: Using Indigenous-specific determinants of health to predict substance use among young pregnant-involved Indigenous women in Canada".

The Cedar Project: mortality among young Indigenous people who use drugs in British Columbia.

BACKGROUND: Young Indigenous people, particularly those involved in the child welfare system, those entrenched in substance use and those living with HIV or hepatitis C, are dying prematurely. We report mortality rates among young Indigenous people who use drugs in British Columbia and explore predictors of mortality over time. METHODS: We analyzed data collected every 6 months between 2003 and 2014 by the Cedar Project, a prospective cohort study involving young Indigenous people who use illicit drugs in Vancouver and Prince George, BC. We calculated age-standardized mortality ratios using Indigenous and Canadian reference populations. We identified predictors of mortality using time-dependent Cox proportional hazard regression. RESULTS: Among 610 participants, 40 died between 2003 and 2014, yielding a mortality rate of 670 per 100 000 person-years. Young Indigenous people who used drugs were 12.9 (95% confidence interval [CI] 9.2-17.5) times more likely to die than all Canadians the same age and were 7.8 (95% CI 5.6-10.6) times more likely to die than Indigenous people with Status in BC. Young women and those using drugs by injection were most affected. The leading causes of death were overdose (n = 15 [38%]), illness (n = 11 [28%]) and suicide (n = 5 [12%]). Predictors of mortality included having hepatitis C at baseline (adjusted hazard ratio [HR] 2.76, 95% CI 1.47-5.16), previous attempted suicide (adjusted HR 1.88, 95% CI 1.01-3.50) and recent overdose (adjusted HR 2.85, 95% CI 1.00-8.09). INTERPRETATION: Young Indigenous people using drugs in BC are dying at an alarming rate, particularly young women and those using injection drugs. These deaths likely reflect complex intersections of historical and present-day injustices, substance use and barriers to care.

The Cedar Project: Using Indigenous-specific determinants of health to predict substance use among young pregnant-involved Indigenous women in Canada.

BACKGROUND: Indigenous women in Canada have been hyper-visible in research, policy and intervention related to substance use during pregnancy; however, little is known about how the social determinants of health and substance use prior to, during, and after pregnancy intersect. The objectives of this study were to describe the social contexts of pregnant-involved young Indigenous women who use substances and to explore if an Indigenous-Specific Determinants of Health Model can predict substance use among this population. METHODS: Using descriptive statistics and hierarchical logistic regression guided by mediation analysis, the social contexts of pregnant-involved young Indigenous women who use illicit drugs' lives were explored and the Integrated Life Course and Social Determinants Model of Aboriginal Health's ability to predict heavy versus light substance use in this group was tested (N = 291). RESULTS: Important distal determinants of substance use were identified including residential school histories, as well as protective factors, such as sex abuse reporting and empirical evidence for including Indigenous-specific determinants of health as important considerations in understanding young Indigenous women's experiences with pregnancy and substance use was provided. CONCLUSIONS: This analysis provided important insight into the social contexts of women who have experiences with pregnancy as well as drug and/or alcohol use and highlighted the need to include Indigenous-specific determinants of health when examining young Indigenous women's social, political and historical contexts in relation to their experiences with pregnancy and substance use.

Mapping the social determinants of substance use for pregnant-involved young Aboriginal women.

There is a dearth of knowledge about the social determinants of substance use among young pregnant-involved Indigenous women in Canada from their perspectives. As part of life history interviews, 17 young pregnant-involved Indigenous women with experiences with substances completed a participant-generated mapping activity CIRCLES (Charting Intersectional Relationships in the Context of Life Experiences with Substances). As women created their maps, they discussed how different social determinants impacted their experiences with pregnancy and substance use. The social determinants identified and used by women to explain determinants of their substance use were grouped into 10 themes: traumatic life histories; socioeconomic status; culture, identity and spirituality; shame and guilt; mental wellness; family connections; romantic and platonic relationships; strength and hope; mothering; and the intersections of determinants. We conclude that understanding the context and social determinants of substance use from a woman-informed perspective is paramount to informing effective and appropriate programs to support young Indigenous women who use substances.

Understanding the Life Histories of Pregnant-Involved Young Aboriginal Women With Substance Use Experiences in Three Canadian Cities.

Despite attention paid to substance use during pregnancy, understandings of young Aboriginal women's experiences based on their perspectives have been virtually absent in the published literature. This study's objective was to understand the life experiences of pregnant-involved young Aboriginal women with alcohol and drugs. Semi-structured interviews to gather life histories were conducted with 23 young Aboriginal women who had experiences with pregnancy, and alcohol and drug use. Transcribed interviews were analyzed for themes to describe the social and historical contexts of women's experiences and their self-representations. The findings detail women's strategies for survival, inner strength, and capacities for love, healing, and resilience. Themes included the following: intersectional identities, life histories of trauma (abuse, violence, and neglect; intergenerational trauma; separations and connections), the ever-presence of alcohol and drugs, and the highs and lows of pregnancy and mothering. The findings have implications for guiding policy and interventions for supporting women and their families.

The Alcohol Use Disorders Identification Test (AUDIT): Exploring the Factor Structure and Cutoff Thresholds in a Representative Post-Conflict Population in Northern Uganda.

AIMS: Despite increased use of the Alcohol Use Disorders Identification Test (AUDIT) in sub-Saharan Africa, few studies have assessed its underlying conceptual framework, and none have done so in post-conflict settings. Further, significant inconsistencies exist between definitions used for problematic consumption. Such is the case in Uganda, facing one of the highest per-capita alcohol consumption levels regionally, which is thought to be hindering rebuilding in the North after two decades of civil war. This study explores the impact of varying designation cutoff thresholds in the AUDIT as well as its conceptual factor structure in a representative sample of the population. METHODS: In all, 1720 Cango Lyec Project participants completed socio-economic and mental health questionnaires, provided blood samples and took the AUDIT. Participant characteristics and consumption designations were compared at AUDIT summary score thresholds of ≥3, ≥5 and ≥8. Confirmatory factor analyses (CFA) explored one-, two- and three-factor level models overall and by sex with relative and absolute fit indicators. RESULTS: There were no significant differences in participant demographic characteristics between thresholds. At higher cutoffs, the test increased in specificity to identify those with hazardous drinking, disordered drinking and suffering from alcohol-related harms. All conceptual models indicated good fit, with three-factor models superior overall and within both sexes. CONCLUSION: In Northern Uganda, a three-factor AUDIT model best explores alcohol use in the population and is appropriate for use in both sexes. Lower cutoff thresholds are recommended to identify those with potentially disordered drinking to best plan effective interventions and treatments. SHORT SUMMARY: A CFA of the AUDIT showed good fit for one-, two, and three-factor models overall and by sex in a representative sample in post-conflict Northern Uganda. A three-plus total AUDIT cutoff score is suggested to screen for hazardous drinking in this or similar populations.

"The Cango Lyec Project - Healing the Elephant": HIV related vulnerabilities of post-conflict affected populations aged 13-49 years living in three Mid-Northern Uganda districts.

BACKGROUND: The protracted war between the Government of Uganda and the Lord's Resistance Army in Northern Uganda (1996-2006) resulted in widespread atrocities, destruction of health infrastructure and services, weakening the social and economic fabric of the affected populations, internal displacement and death. Despite grave concerns that increased spread of HIV/AIDS may be devastating to post conflict Northern Uganda, empirical epidemiological data describing the legacy of the war on HIV infection are scarce. METHODS: The 'Cango Lyec' Project is an open cohort study involving conflict-affected populations living in three districts of Gulu, Nwoya and Amuru in mid-northern Uganda. Between November 2011 and July 2012, 8 study communities randomly selected out of 32, were mapped and house-to-house census conducted to enumerate the entire community population. Consenting participants aged 13-49 years were enrolled and interviewer-administered data were collected on trauma, depression and socio-demographic-behavioural characteristics, in the local Luo language. Venous blood was taken for HIV and syphilis serology. Multivariable logistic regression was used to determine factors associated with HIV prevalence at baseline. RESULTS: A total of 2954 participants were eligible, of whom 2449 were enrolled. Among 2388 participants with known HIV status, HIV prevalence was 12.2% (95%CI: 10.8-13.8), higher in females (14.6%) than males (8.5%, p < 0.001), higher in Gulu (15.2%) than Nwoya (11.6%, p < 0.001) and Amuru (7.5%, p = 0.006) districts. In this post-conflict period, HIV infection was significantly associated with war trauma experiences (Adj. OR = 2.50; 95%CI: 1.31-4.79), the psychiatric problems of PTSD (Adj. OR = 1.44; 95%CI: 1.06-1.96), Major Depressive Disorder (Adj. OR = 1.89; 95%CI: 1.28-2.80) and suicidal ideation (Adj. OR = 1.87; 95%CI: 1.34-2.61). Other HIV related vulnerabilities included older age, being married, separated, divorced or widowed, residing in an urban district, ulcerative sexually transmitted infections, and staying in a female headed household. There was no evidence in this study to suggest that people with a history of abduction were more likely to be HIV positive. CONCLUSIONS: HIV prevalence in this post conflict-affected population is high and is significantly associated with age, trauma, depression, history of ulcerative STIs, and residing in more urban districts. Evidence-based HIV/STI prevention programs and culturally safe, gender and trauma-informed are urgently needed.