Healthcare system action on employment as a social determinant of health in people living with HIV: A qualitative study.

BACKGROUND: Employment is a key social determinant of health. People living with HIV (PLWH) have higher unemployment rates than the general population. Vocational rehabilitation services have been shown to have significant and positive impact on employment status for PLWH. Understanding whether integrating vocational rehabilitation with health care services is acceptable, from the perspectives of PLWH and their health care providers, is an area that is understudied. METHODS: We conducted a qualitative study and collected data from focus groups and interviews to understand the perspectives of stakeholders regarding the potential for vocational rehabilitation and health care integration. We completed five focus groups with 45 health care providers and one-to-one interviews with 23 PLWHs. Participants were sampled from infectious disease, primary care clinics, and AIDS Service Organizations in Toronto and Ottawa, Canada. Interviews were audio-recorded and transcribed. We conducted a reflexive thematic analysis of the transcripts. FINDINGS: We found health care providers have little experience assisting patients with employment and PLWH had little experience receiving employment interventions from their health care team. This lack of integration between health care and vocational services was related to uncertainties around drug coverage, physician role and living with an episodic disability. Health care providers thought that there is potential for a larger role for health care clinics in providing employment interventions for PLWH however patients were divided. Some PLWH suggest that health care providers could provide advice on the disclosure of status, work limitations and act as advocates with employers. INTERPRETATION: Health care providers and some PLWH recognize the importance of integrating health services with vocational services but both groups have little experience with implementing these types of interventions. Thus, there needs to be more study of such interventions, including the processes entailed and outcomes they aim to achieve.

Clinical public health: harnessing the best of both worlds in sickness and in health. / Santé publique clinique : exploiter le meilleur des deux mondes pour la santé comme pour le traitement des maladies.

INTRODUCTION: Effective, sustained collaboration between clinical and public health professionals can lead to improved individual and population health. The concept of clinical public health promotes collaboration between clinical medicine and public health to address complex, real-world health challenges. In this commentary, we describe the concept of clinical public health, the types of complex problems that require collaboration between individual and population health, and the barriers towards and applications of clinical public health that have become evident during the COVID-19 pandemic. RATIONALE: The focus of clinical medicine on the health of individuals and the aims of public health to promote and protect the health of populations are complementary. Interdisciplinary collaborations at both levels of health interventions are needed to address complex health problems. However, there is a need to address the disciplinary, cultural and financial barriers to achieving greater and sustained collaboration. Recent successes, particularly during the COVID-19 pandemic, provide a model for such collaboration between clinicians and public health practitioners. CONCLUSION: A public health approach that fosters ongoing collaboration between clinical and public health professionals in the face of complex health threats will have greater impact than the sum of the parts.

INTRODUCTION: Une collaboration efficace et soutenue entre cliniciens et professionnels en santé publique peut améliorer la santé des individus et la santé de la population. Le concept de santé publique clinique favorise cette collaboration entre médecine clinique et santé publique et permet de relever des défis complexes en matière de santé. Dans ce commentaire, nous décrivons le concept de santé publique clinique, les types de problèmes complexes qui nécessitent une collaboration entre les professionnels responsables de la santé des individus et ceux responsables de la santé de la population, de même que les obstacles à la santé publique clinique et les applications de la santé publique clinique qui ont émergé pendant la pandémie de COVID-19. ARGUMENTAIRE: Il existe une complémentarité entre la médecine clinique, qui est axée sur la santé des individus, et la santé publique, qui est axée sur la promotion et la protection de la santé des populations. Une collaboration entre ces deux disciplines est nécessaire pour résoudre les problèmes de santé complexes. Pour ce faire, toutefois, il convient de s'attaquer aux obstacles relatifs aux disciplines, ainsi qu'aux obstacles culturels et financiers qui empêchent une collaboration accrue et durable en la matière. Les succès récents, particulièrement durant la pandémie de COVID-19, constituent un modèle de collaboration de ce type entre cliniciens et praticiens en santé publique. CONCLUSION: Une approche en matière de santé publique qui favorise une collaboration permanente entre cliniciens et professionnels en santé publique pour lutter contre des menaces sanitaires complexes aura plus d'impact que la somme de ses parties.

Low human papillomavirus vaccine uptake among women engaged in HIV care in Ontario, Canada.

Women living with HIV are at higher risk for human papillomavirus (HPV)-related dysplasia and cancers and thus are prioritized for HPV vaccination. We measured HPV vaccine uptake among women engaged in HIV care in Ontario, Canada, and identified socio-demographic, behavioural, and clinical characteristics associated with HPV vaccination. During annual interviews from 2017 to 2020, women participating in a multi-site, clinical HIV cohort responded to a cross-sectional survey on HPV vaccine knowledge and receipt. We used logistic regression to derive age-adjusted odds ratios and 95% confidence intervals (CI) for factors associated with self-reported vaccine initiation (≥1 dose) or series completion (3 doses). Among 591 women (median age = 48 years; interquartile range = 40-56 years), 13.2% (95%CI = 10.5-15.9%) had received ≥1 dose. Of those vaccinated, 64.6% had received 3 doses. Vaccine initiation (≥1 dose) was significantly higher among women aged 20-29 years at 31.0% but fell to 13.9% in those aged 30-49 years and < 10% in those aged ≥50 years. After age adjustment, vaccine initiation was significantly associated with being employed (vs. unemployed but seeking work), income $40,000-$59,999 (vs. <$20,000), being married/common-law (vs. single), living with children, immigrating to Canada >5 years ago (vs. immigrating ≤5 years ago), never smoking (vs. currently smoking), and being in HIV care longer (per 10 years). Similar factors were identified for series completion (3 doses). HPV vaccine uptake remains low among women living with HIV in our cohort despite regular engagement in care. Recommendations for improving uptake include education of healthcare providers, targeted community outreach, and public funding of HPV vaccination.

Uncovering SARS-COV-2 vaccine uptake and COVID-19 impacts among First Nations, Inuit and Métis Peoples living in Toronto and London, Ontario.

BACKGROUND: First Nations, Inuit and Métis Peoples across geographies are at higher risk of SARS-CoV-2 infection and COVID-19 because of high rates of chronic disease, inadequate housing and barriers to accessing health services. Most Indigenous Peoples in Canada live in cities, where SARS-CoV-2 infection is concentrated. To address gaps in SARS-CoV-2 information for these urban populations, we partnered with Indigenous agencies and sought to generate rates of SARS-CoV-2 testing and vaccination, and incidence of infection for First Nations, Inuit and Métis living in 2 Ontario cities. METHODS: We drew on existing cohorts of First Nations, Inuit and Métis adults in Toronto (n = 723) and London (n = 364), Ontario, who were recruited using respondent-driven sampling. We linked to ICES SARS-CoV-2 databases and prospectively monitored rates of SARS-CoV-2 testing, diagnosis and vaccination for First Nations, Inuit and Métis, and comparator city and Ontario populations. RESULTS: We found that SARS-CoV-2 testing rates among First Nations, Inuit and Métis were higher in Toronto (54.7%, 95% confidence interval [CI] 48.1% to 61.3%) and similar in London (44.5%, 95% CI 36.0% to 53.1%) compared with local and provincial rates. We determined that cumulative incidence of SARS-CoV-2 infection was not significantly different among First Nations, Inuit and Métis in Toronto (7364/100 000, 95% CI 2882 to 11 847) or London (7707/100 000, 95% CI 2215 to 13 200) compared with city rates. We found that rates of vaccination among First Nations, Inuit and Métis in Toronto (58.2%, 95% CI 51.4% to 64.9%) and London (61.5%, 95% CI 52.9% to 70.0%) were lower than the rates for the 2 cities and Ontario. INTERPRETATION: Although Ontario government policies prioritized Indigenous populations for SARS-CoV-2 vaccination, vaccine uptake was lower than in the general population for First Nations, Inuit and Métis Peoples in Toronto and London. Ongoing access to culturally safe testing and vaccinations is urgently required to avoid disproportionate hospital admisson and mortality related to COVID-19 in these communities.

Defining Clinical Public Health.

PURPOSE: To solve complex health issues, an innovative and multidisciplinary framework is necessary. The Clinical Public Health (CPH) Division was established at the University of Toronto (UofT), Canada to foster inte-gration of primary care, preventive medicine and public health in education, practice and research. To better understand how the construct of CPH might be applied, we surveyed clinicians, researchers and public health professionals affiliated with the CPH Division to assess their understanding of the CPH concept and its utility in fostering broad collaboration. METHODS: A two-wave anonymous survey of the active faculty of the CPH Division, UofT was conducted across Canada. Wave 1 participants (n = 187; 2016) were asked to define CPH, while Wave 2 participants (n = 192; 2017) were provided a synthesis of Wave 1 results and asked to rank each definition. Both waves were asked about the need for a common definition, and to comment on CPH. RESULTS: Response rates for the first and second waves were 25% and 22%, respectively. Of the six definitions of CPH from Wave 1, "the intersection of clinical practice and public health," was most highly ranked by Wave 2 participants. Positive perceptions of CPH included multidisciplinary collaboration, new fields and insights, forward thinking and innovation. Negative perceptions included CPH being a confusing term, too narrow in scope or too clinical. CONCLUSION: The concept of Clinical Public Health can foster multidisciplinary collaboration to address com-plex health issues because it provides a useful framework for bringing together key disciplines and diverse professional specialties.

The impact of routine HIV drug resistance testing in Ontario: A controlled interrupted time series study.

BACKGROUND: Knowledge of HIV drug resistance informs the choice of regimens and ensures that the most efficacious options are selected. In January 2014, a policy change to routine resistance testing was implemented in Ontario, Canada. The objective of this study was to investigate the policy change impact of routine resistance testing in people with HIV in Ontario, Canada since January 2014. METHODS: We used data on people with HIV living in Ontario from administrative databases of the Institute for Clinical Evaluative Sciences (ICES) and Public Health Ontario (PHO), and ran ordinary least squares (OLS) models of interrupted time series to measure the levels and trends of 2-year mortality, 2-year hospitalizations and 2-year emergency department visits before (2005-2013) and after the policy change (2014-2017). Outcomes were collected in biannual periods, generating 18 periods before the intervention and 8 periods after. We included a control series of people who did not receive a resistance test within 3 months of HIV diagnosis. RESULTS: Data included 12,996 people with HIV, of which 8881 (68.3%) were diagnosed between 2005 and 2013, and 4115 (31.7%) were diagnosed between 2014 and 2017. Policy change to routine resistance testing within 3 months of HIV diagnosis led to a decreasing trend in 2-year mortality of 0.8% every six months compared to the control group. No significant differences in hospitalizations or emergency department visits were noted. INTERPRETATION: The policy of routine resistance testing within three months of diagnosis is beneficial at the population level.

Using concept mapping to explore the challenges associated with affording and accessing medications among people living with HIV in Ontario, Canada.

Antiretroviral medications are expensive, and people living with HIV often experience challenges accessing and paying for medication due to various obstacles. We used concept mapping to explore the challenges people living with HIV in Ontario, Canada, face when accessing medication. In brainstorming, 68 participants generated 447 statements in response to the focus prompt "Some people living with HIV have trouble getting and paying for prescription drugs because … ". These were consolidated into 77 statements, which were sorted (n = 30) and rated (n = 32) on importance and commonality. A ten-cluster concept map consisting of individual- and health system-related clusters was generated. Clusters included: (1) Stigma, (2) Medication-Related Issues, (3) Individual Challenges, (4) Basic Needs, (5) Immigration, (6) Coverage, (7) Trillium Drug Program, (8) Access to Services, (9) System-Level Issues and (10) Access to Professional Services. Statements in Coverage and Basic Needs were rated most important and common although there was variability by Ontario residence and drug coverage mechanisms. Strategies to address challenges were generated in Interpretation (n = 25 participants). Given that continuous access to antiretroviral therapy is necessary to fully realize treatment benefits, policies and interventions that address these challenges are needed.

Overview of systematic reviews on strategies to improve treatment initiation, adherence to antiretroviral therapy and retention in care for people living with HIV: part 1.

OBJECTIVES: We sought to map the evidence and identify interventions that increase initiation of antiretroviral therapy, adherence to antiretroviral therapy and retention in care for people living with HIV at high risk for poor engagement in care. METHODS: We conducted an overview of systematic reviews and sought for evidence on vulnerable populations (men who have sex with men (MSM), African, Caribbean and Black (ACB) people, sex workers (SWs), people who inject drugs (PWID) and indigenous people). We searched PubMed, Excerpta Medica dataBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and the Cochrane Library in November 2018. We screened, extracted data and assessed methodological quality in duplicate and present a narrative synthesis. RESULTS: We identified 2420 records of which only 98 systematic reviews were eligible. Overall, 65/98 (66.3%) were at low risk of bias. Systematic reviews focused on ACB (66/98; 67.3%), MSM (32/98; 32.7%), PWID (6/98; 6.1%), SWs and prisoners (both 4/98; 4.1%). Interventions were: mixed (37/98; 37.8%), digital (22/98; 22.4%), behavioural or educational (9/98; 9.2%), peer or community based (8/98; 8.2%), health system (7/98; 7.1%), medication modification (6/98; 6.1%), economic (4/98; 4.1%), pharmacy based (3/98; 3.1%) or task-shifting (2/98; 2.0%). Most of the reviews concluded that the interventions effective (69/98; 70.4%), 17.3% (17/98) were neutral or were indeterminate 12.2% (12/98). Knowledge gaps were the types of participants included in primary studies (vulnerable populations not included), poor research quality of primary studies and poorly tailored interventions (not designed for vulnerable populations). Digital, mixed and peer/community-based interventions were reported to be effective across the continuum of care. CONCLUSIONS: Interventions along the care cascade are mostly focused on adherence and do not sufficiently address all vulnerable populations.

Cohort profile: Development and profile of a population-based, retrospective cohort of diagnosed people living with HIV in Ontario, Canada (Ontario HIV Laboratory Cohort).

PURPOSE: Population-based cohorts of diagnosed people living with HIV (PLWH) are limited worldwide. In Ontario, linked HIV diagnostic and viral load (VL) test databases are centralised and contain laboratory data commonly used to measure engagement in HIV care. We used these linked databases to create a population-based, retrospective cohort of diagnosed PLWH in Ontario, Canada. PARTICIPANTS: A datamart was created by integrating diagnostic and VL databases and linking records at the individual level. These databases contain information on laboratory test results and sociodemographic/clinical information collected on requisition/surveillance forms. Datamart individuals enter our cohort with the first record of a nominal HIV-positive diagnostic test (1985-2015) or VL test (1996-2015), and remain unless administratively lost to follow-up (LTFU; no VL test for >2 years and no VL test in later years). Non-nominal diagnostic tests are excluded as they lack identifying information to permit linkage to other tests. However, individuals diagnosed non-nominally are included in the cohort with record of a VL test. The LTFU rule is applied to indirectly censor for death/out-migration. FINDINGS TO DATE: As of the end of 2015, the datamart contained 40 372 HIV-positive diagnostic tests and 23 851 individuals with ≥1 VL test. Almost half (46.3%) of the diagnostic tests were non-nominal and excluded, although this was lower (~15%) in recent years. Overall, 29 587 individuals have entered the cohort-contributing 229 302 person-years of follow-up since 1996. Between 2000 and 2015, the number of diagnosed PLWH (cohort individuals not LTFU) increased from 8859 to 16 110, and the percent who were aged ≥45 years increased from 29.1% to 62.6%. The percent of diagnosed PLWH who were virally suppressed (<200 copies/mL) increased from 40.7% in 2000 to 79.5% in 2015. FUTURE PLANS: We plan to conduct further analyses of HIV care engagement and link to administrative databases with information on death, migration, physician billing claims and prescriptions. Linkage to other data sources will address cohort limitations and expand research opportunities.

Defining and measuring health equity in research on task shifting in high-income countries: A systematic review.

INTRODUCTION: Task shifting interventions have been implemented to improve health and address health inequities. Little is known about how inequity and vulnerability are defined and measured in research on task shifting. We conducted a systematic review to identify how inequity and vulnerability are identified, defined and measured in task shifting research from high-income countries. METHODS AND ANALYSIS: We implemented a novel search process to identify programs of research concerning task shifting interventions in high-income countries. We searched MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and CENTRAL to identify articles published from 2004 to 2016. Each program of research incorporated a "parent" randomized trial and "child" publications or sub-studies arising from the same research group. Two investigators extracted (1) study details, (2) definitions and measures of health equity or population vulnerability, and (3) assessed the quality of the reporting and measurement of health equity and vulnerability using a five-point scale developed for this study. We summarized the findings using a narrative approach. RESULTS: Fifteen programs of research met inclusion criteria, involving 15 parent randomized trials and 62 child publications. Included programs of research were all undertaken in the United States, among Hispanic- (5/15), African- (2/15), and Korean-Americans (1/15), and low socioeconomic status (2/15), rural (2/15) and older adult populations (2/15). Task shifting interventions included community health workers, peers, and a variety of other non-professional and lay workers to address a range of non-communicable diseases. Some research provided robust analyses of the affected populations' health inequities and demonstrated how a task shifting intervention redressed those concerns. Other studies provided no such definitions and measured only biomedical endpoints. CONCLUSION: Included studies vary substantially in the definition and measurement of health inequity and vulnerability. A more precise theoretical and evaluative framework for task shifting is recommended to effectively achieve the goal of equitable health.

Potential use of supervised injection services among people who inject drugs in a remote and mid-size Canadian setting.

BACKGROUND: While supervised injection services (SIS) feasibility research has been conducted in large urban centres across North America, it is unknown whether these services are acceptable among people who inject drugs (PWID) in remote, mid-size cities. We assessed willingness to use SIS and expected frequency of SIS use among PWID in Thunder Bay, a community in Northwestern, Ontario, Canada, serving people from suburban, rural and remote areas of the region. METHODS: Between June and October 2016, peer research associates administered surveys to PWID. Sociodemographic characteristics, drug use and behavioural patterns associated with willingness to use SIS and expected frequency of SIS use were estimated using bivariable and multivariable logistic regression models. Design preferences and amenities identified as important to provide alongside SIS were assessed descriptively. RESULTS: Among 200 PWID (median age, IQR: 35, 28-43; 43% female), 137 (69%) reported willingness to use SIS. In multivariable analyses, public injecting was positively associated with willingness to use (Adjusted Odds Ratio (AOR): 4.15; 95% confidence interval (CI): 2.08-8.29). Among those willing to use SIS, 87 (64%) said they would always/usually use SIS, while 48 (36%) said they would sometime/occasionally use SIS. In multivariable analyses, being female (AOR: 2.44; 95% CI: 1.06-5.65) and reporting injecting alone was positively associated with higher expected frequency of use (AOR: 2.59; 95% CI: 1.02-6.58). CONCLUSIONS: Our findings suggest that SIS could play a role in addressing the harms of injection drug use in remote and mid-sized settings particularly for those who inject in public, as well as women and those who inject alone, who report higher expected frequency of SIS use. Design preferences of local PWID, in addition to differences according to gender should be taken into consideration to maximize the uptake of SIS, alongside existing health and social service provisions available to PWID.

Trends in HIV care cascade engagement among diagnosed people living with HIV in Ontario, Canada: A retrospective, population-based cohort study.

BACKGROUND: The HIV cascade is an important framework for assessing systems of care, but population-based assessment is lacking for most jurisdictions worldwide. We measured cascade indicators over time in a population-based cohort of diagnosed people living with HIV (PLWH) in Ontario, Canada. METHODS: We created a retrospective cohort of diagnosed PLWH using a centralized laboratory database with HIV diagnostic and viral load (VL) test records linked at the individual-level. Individuals enter the cohort with record of a nominal HIV-positive diagnostic test or VL test, and remain unless administratively lost to follow-up (LTFU, >2 consecutive years with no VL test and no VL test in later years). We calculated the annual percent of diagnosed PLWH (cohort individuals not LTFU) between 2000 and 2015 who were in care (≥1 VL test), on ART (as documented on VL test requisition) or virally suppressed (<200 copies/ml). We also calculated time from diagnosis to linkage to care and viral suppression among individuals newly diagnosed with HIV. Analyses were stratified by sex and age. Upper/lower bounds were calculated using alternative indicator definitions. RESULTS: The number of diagnosed PLWH increased from 8,859 (8,859-11,389) in 2000 to 16,110 (16,110-17,423) in 2015. Over this 16-year period, the percent of diagnosed PLWH who were: in care increased from 81% (63-81%) to 87% (81-87%), on ART increased from 55% (34-60%) to 81% (70-82%) and virally suppressed increased from 41% (23-46%) to 80% (67-81%). Between 2000 and 2014, the percent of newly diagnosed individuals who linked to care within three months of diagnosis or achieved viral suppression within six months of diagnosis increased from 67% to 82% and from 22% to 42%, respectively. Estimates were generally lower for females and younger individuals. DISCUSSION: HIV cascade indicators among diagnosed PLWH in Ontario improved between 2000 and 2015, but gaps still remain-particularly for younger individuals.

One Size Fits (n)One: The Influence of Sex, Age, and Sexual Human Immunodeficiency Virus (HIV) Acquisition Risk on Racial/Ethnic Disparities in the HIV Care Continuum in the United States.

BACKGROUND: The United States National HIV/AIDS Strategy established goals to reduce disparities in retention in human immunodeficiency virus (HIV) care, antiretroviral therapy (ART) use, and viral suppression. The impact of sex, age, and sexual HIV acquisition risk (ie, heterosexual vs same-sex contact) on the magnitude of HIV-related racial/ethnic disparities is not well understood. METHODS: We estimated age-stratified racial/ethnic differences in the 5-year restricted mean percentage of person-time spent in care, on ART, and virally suppressed among 19 521 women (21.4%), men who have sex with men (MSM; 59.0%), and men who have sex with women (MSW; 19.6%) entering HIV care in the North American AIDS Cohort Collaboration on Research and Design between 2004 and 2014. RESULTS: Among women aged 18-29 years, whites spent 12.0% (95% confidence interval [CI], 1.1%-20.2%), 9.2% (95% CI, .4%-20.4%), and 13.5% (95% CI, 2.7%-22.5%) less person-time in care, on ART, and virally suppressed, respectively, than Hispanics. Black MSM aged ≥50 years spent 6.3% (95% CI, 1.3%-11.7%), 11.0% (95% CI, 4.6%-18.1%), and 9.7% (95% CI, 3.6%-16.8%) less person-time in these stages, respectively, than white MSM ≥50 years of age. Among MSM aged 40-49 years, blacks spent 9.8% (95% CI, 2.4%-16.5%) and 11.9% (95% CI, 3.8%-19.3%) less person-time on ART and virally suppressed, respectively, than whites. CONCLUSIONS: Racial/ethnic differences in HIV care persist in specific populations defined by sex, age, and sexual HIV acquisition risk. Clinical and public health interventions that jointly target these demographic factors are needed.

Public prescription drug plan coverage for antiretrovirals and the potential cost to people living with HIV in Canada: a descriptive study.

BACKGROUND: Antiretrovirals are expensive and people living with HIV may experience a range of financial burdens when accessing these medications. Our aim was to describe the policy of all Canadian public drug insurance programs for antiretroviral drugs and illustrated how these policies might affect patients' annual out-of-pocket expenditures. METHODS: In December 2017, we reviewed public drug programs offering antiretroviral coverage in Canada using government websites to summarize eligibility criteria. We estimated the annual out-of-pocket costs incurred by people living with HIV by applying the cost-sharing rules to 2 hypothetical cases, a single man and a married woman with a net household income of $39 000 and $80 000, respectively, receiving identical prescriptions in different jurisdictions. RESULTS: We observed substantial variation in the subsidy provided based mainly on geography, income and age. All 5 federal programs and 6 of 13 provincial and territorial jurisdictions offered universal coverage. In the remaining regions, patients spend up to several thousand dollars annually depending on income (Manitoba), age and income (Ontario, Saskatchewan) and age, income and drug costs (Quebec and Newfoundland and Labrador). We found the greatest variation for our higher income case, with out-of-pocket expenses ranging from 0 to over 50% of the antiretroviral cost. INTERPRETATION: There is considerable inter- and intra-jurisdiction heterogeneity in the cost-sharing policies for antiretrovirals across Canada's public drug programs. Policy reforms that either eliminate or set national standards for copayments, deductibles or premiums would minimize variation and could reduce the risk of cost-associated non-adherence to HIV therapy.

Strategies to improve adherence to antiretroviral therapy and retention in care for people living with HIV in high-income countries: a protocol for an overview of systematic reviews.

INTRODUCTION: While access to antiretroviral therapy (ART) for people living with HIV has expanded in recent years, additional efforts are required to support adherence to medication and retention in care. Interventions should be applicable in real-world settings and amenable to widespread use. The objectives of this overview are to identify effective pragmatic interventions that increase adherence to ART and retention in care for people living with HIV at high risk for suboptimal adherence and retention in high-income countries. METHODS AND ANALYSIS: We will conduct an overview of systematic reviews of studies on interventions which target improved adherence to medication and retention in care among high-risk people living with HIV in high-income countries (men who have sex with men, African, Caribbean and black people, sex workers, people who inject drugs, indigenous people and other socially marginalised groups). We will search the following databases: PubMed, EMBASE (Exerpta Medica Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, Web of Science and the Cochrane Library. We will conduct screening, data extraction and assessment of methodological quality of the systematic reviews. Analysis will be narrative. Our findings will be interpreted in light of the certainty of the evidence, level of pragmatism, setting and population of interest. ETHICS AND DISSEMINATION: Only published secondary data will be used in this study, and therefore ethics approval is not required. Our findings will be disseminated as peer-reviewed manuscripts, conference abstracts and through community activities. The findings from this overview will inform a mixed-methods study among people living with HIV and health workers in Ontario, Canada.

Defining and measuring health equity effects in research on task shifting interventions in high-income countries: a systematic review protocol.

INTRODUCTION: Task shifting interventions are intended to both deliver clinically effective treatments to reduce disease burden and address health inequities or population vulnerability. Little is known about how health equity and population vulnerability are defined and measured in research focused on task shifting. This systematic review will address the following questions: Among task shifting interventions in high-income settings that have been studied using randomised controlled trials or variants, how are health inequity or population vulnerability identified and defined? What methods and indicators are used to describe, characterise and measure the population's baseline status and the intervention's impacts on inequity and vulnerability? METHODS AND ANALYSIS: Studies were identified through database searches (MEDLINE, Embase, CINAHL, PsycINFO and Web of Science). Eligible studies will be randomised controlled trials published since 2004, conducted in high-income countries, concerning task shifting interventions to treat any disease, in any population that may face health disadvantage as defined by the PROGRESS-Plus framework (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, social capital, socioeconomic position, age, disability, sexual orientation, other vulnerable groups). We will conduct independent and duplicate title and abstract screening, then identify related papers from the same programme of research through further database and manual searching. From each programme of research, we will extract study details, and definitions and measures of health equity or population vulnerability based on the PROGRESS-Plus framework. Two investigators will assess the quality of reporting and measurement related to health equity and vulnerability using a scale developed for this study. A narrative synthesis will highlight similarities and differences between the gathered studies and offer critical analyses and implications. ETHICS AND DISSEMINATION: This review does not involve primary data collection, does not constitute research on human subjects and is not subject to additional institutional ethics review or informed consent procedures. Dissemination will include open-access peer-reviewed publication and academic conference presentations.PROSPERO Registration Number CRD42017049959.

Correction to: Identifying common barriers and facilitators to linkage and retention in chronic disease care in western Kenya.

After the publication of the original article [1], it was highlighted that Fig. 1 was incorrectly labeled.

The impact of drug coverage on viral suppression among people living with HIV in Ontario, Canada.

OBJECTIVES: We investigated the effect of drug coverage on viral suppression (sVL) in Ontario, Canada, where there is no universal coverage of prescription drugs, including antiretroviral therapy (ART). METHODS: Ontarians without employment coverage may be eligible for varying degrees of coverage through government-sponsored programs. Remaining individuals pay all expenses entirely out of pocket. Among participants on ART enrolled in the Ontario HIV Treatment Network Cohort Study (OCS) who were interviewed in 2008-2013 with known or imputable drug coverage, we estimated the prevalence with sVL (< 200 copies/mL) as of their last viral load each year. We calculated prevalence ratios (PR) according to time-updated socio-economic and behavioural factors using multivariable generalized estimating equations with a log-link function. Multiple imputation was used to assess the sensitivity of these findings to different assumed missing data models. RESULTS: One thousand two hundred forty-seven participants were included (3463 person-years). Compared to study participants with employer coverage, individuals covered through the Ontario Drug Benefit (ODB) were less likely to be suppressed (PR, 95% confidence interval (CI) 0.96, 0.93-0.98). After multivariable adjustment, ODB remained independently associated with less success in achieving sVL (adjusted PR, 95% CI 0.98, 0.95-0.99). These findings were robust to different assumptions about the missing data. CONCLUSION: Our findings suggest that drug coverage can affect viral suppression in our setting. Further research is needed to identify the mechanisms by which coverage interacts with individual patient factors to affect viral suppression. Mechanisms to improve access and coverage for ART are needed.

Syringe sharing among people who inject drugs in London, Canada.

OBJECTIVES: London, Ontario, is facing an outbreak of HIV among people who inject drugs (PWID), as well as persistently high levels of hepatitis C virus (HCV). Syringe sharing is the primary driver of HIV and HCV transmission risks among PWID, however, little is known about factors contributing to syringe sharing in this setting. Therefore, we sought to characterize syringe sharing and its correlates among London PWID. METHODS: Between March and April, 2016, PWID participated in a survey administered by peer research associates as part of the Ontario Integrated Supervised Injection Services Feasibility Study. Bivariable and multivariable logistic regression models examined associations with syringe sharing (borrowing or lending previously used syringes) over the previous 6 months. A sub-analysis described patterns of borrowing and lending by self-reported HIV and HCV statuses. RESULTS: Of 198 PWID, 44 (22%) reported syringe sharing in the past 6 months. In the multivariable analysis, selling drugs (adjusted odds ratio; AOR = 1.92, 95% CI = 1.20-3.08), daily crystal methamphetamine injection (AOR = 1.66, 95% CI = 1.07-2.59), and identifying as HIV-positive (AOR = 3.11, 95% CI = 1.61-6.01) were independently associated with increased syringe sharing. While not independently associated with syringe sharing, problems accessing syringes were common (13-50%). Self-reported HIV-positive respondents were more likely to report syringe borrowing (p < 0.001), but not lending (p = 0.26). CONCLUSION: We observed a high rate of syringe sharing among London PWID, with sharing being associated with high-intensity injection of crystal methamphetamine, as well as with involvement in drug sales. Considering the current HIV outbreak in London, multi-level prevention efforts are urgently needed.

Viral suppression and viral rebound among young adults living with HIV in Canada.

Describe the prevalence and covariates of viral suppression and subsequent rebound among younger (≤29 years old) compared with older adults.A retrospective clinical cohort study; eligibility criteria: documented HIV infection; resident of Canada; 18 years and over; first antiretroviral regimen comprised of at least 3 individual agents on or after January 1, 2000.Viral suppression and rebound were defined by at least 2 consecutive viral load measurements <50 or >50 HIV-1 RNA copies/mL, respectively, at least 30 days apart, in a 1-year period. Time to suppression and rebound were measured using the Kaplan-Meier method and Life Table estimates. Accelerated failure time models were used to determine factors independently associated with suppression and rebound.Younger adults experienced lower prevalence of viral suppression and shorter time to viral rebound compared with older adults. For younger adults, viral suppression was associated with being male and later era of combination antiretroviral initiation (cART) initiation. Viral rebound was associated with a history of injection drug use, Indigenous ancestry, baseline CD4 cell count >200, and initiating cART with a protease inhibitor (PI) containing regimen.The influence of age on viral suppression and rebound was modest for this cohort. Our analysis revealed that key covariates of viral suppression and rebound for young adults in Canada are similar to those of known importance to older adults. Women, people who use injection drugs, and people with Indigenous ancestry could be targeted by future health interventions.