Hepatitis C virus reinfection after successful treatment with direct-acting antiviral therapy in a large population-based cohort.

BACKGROUND & AIMS: Direct-acting antiviral therapies (DAA) are an important tool for hepatitis C virus (HCV) elimination. However, reinfection among people who inject drugs (PWID) may hamper elimination targets. Therefore, we estimated HCV reinfection rates among DAA-treated individuals, including PWID. METHODS: We analyzed data from the British Columbia Hepatitis Testers Cohort which included ∼1.7 million individuals screened for HCV in British Columbia, Canada. We followed HCV-infected individuals treated with DAAs who achieved a sustained virologic response (SVR) and had ≥1 subsequent HCV RNA measurement to April 22nd, 2018. Reinfection was defined as a positive RNA measurement after SVR. PWID were identified using a validated algorithm and classified based on recent (<3 years) or former (≥3 years before SVR) use. Crude reinfection rates per 100 person-years (PYs) were calculated. Poisson regression was used to model adjusted incidence rate ratios (IRRs) and 95% CIs. RESULTS: Of 4,114 individuals who met the inclusion criteria, most were male (n = 2,692, 65%), born before 1965 (n = 3,411, 83%) and were either recent (n = 875, 21%) or former PWID (n = 1,793, 44%). Opioid-agonist therapy (OAT) was received by 19% of PWID. We identified 40 reinfections during 2,767 PYs. Reinfection rates were higher among recent (3.1/100 PYs; IRR 6.7; 95% CI 1.9-23.5) and former PWID (1.4/100 PYs; IRR 3.7; 95% CI 1.1-12.9) than non-PWID (0.3/100 PYs). Among recent PWID, reinfection rates were higher among individuals born after 1975 (10.2/100 PYs) and those co-infected with HIV (5.7/100 PYs). Only one PWID receiving daily OAT developed reinfection. CONCLUSIONS: Population-level reinfection rates remain elevated after DAA therapy among PWID because of ongoing exposure risk. Engagement of PWID in harm-reduction and support services is needed to prevent reinfections. LAY SUMMARY: Direct-acting antivirals are an effective tool for the treatment of hepatitis C virus, enabling the elimination of the virus. However, some patients who have been successfully treated with direct-acting antivirals are at risk of reinfection. Our findings showed that the risk of reinfection was highest among people with recent injection drug use. Among people who inject drugs, daily use of opioid-agonist therapy was associated with a lower risk of reinfection.

Twin epidemics of new and prevalent hepatitis C infections in Canada: BC Hepatitis Testers Cohort.

BACKGROUND: We characterized the twin epidemics of new and prevalent hepatitis C virus (HCV) infections in British Columbia, Canada to inform prevention, care and treatment programs. METHODS: The BC Hepatitis Testers Cohort (BC-HTC) includes individuals tested for HCV, HIV or reported as a case of HBV, HCV, HIV or active TB between 1990-2013 linked with data on their medical visits, hospitalizations, cancers, prescription drugs and mortality. Prevalent infection was defined as being anti-HCV positive at first test. Those with a negative test followed by a positive test were considered seroconverters or new infections. RESULTS: Of 1,132,855 individuals tested for HCV, 64,634 (5.8 %) were positive and an additional 3092 cases tested positive elsewhere for a total of 67,726. Of 55,781 HCV positive individuals alive at the end of 2013, 7064 were seroconverters while 48,717 had prevalent infection at diagnosis. The HCV positivity rate (11.2 %) was highest in birth cohort 1945-1964 which declined over time. New infections were more likely to be male, 15-34 years of age (born 1965-1984), HIV- or HBV-coinfected, socioeconomically disadvantaged, have problematic drug and alcohol use and a mental health illness. The profile was similar for individuals with prevalent infection, except for lower odds of HBV-coinfection, major mental health diagnoses and birth cohort >1975. CONCLUSIONS: The HCV positivity rate is highest in birth cohort 1945-1964 which represents most prevalent infections. New infections occur in younger birth cohorts who are commonly coinfected with HIV and/or HBV, socioeconomically marginalized, and living with mental illness and addictions.

Continued low uptake of treatment for hepatitis C virus infection in a large community-based cohort of inner city residents.

BACKGROUND & AIMS: Despite advances in HCV treatment, recent data on treatment uptake is sparse. HCV treatment uptake and associated factors were evaluated in a community-based cohort in Vancouver, Canada. METHODS: The CHASE study is a cohort of inner city residents recruited from January 2003-June 2004. HCV status and treatment were retrospectively and prospectively determined through data linkages with provincial virology and pharmacy databases. Logistic regression analyses were used to identify factors associated with HCV treatment uptake. RESULTS: Among 2913, HCV antibody testing was performed in 2405, 64% were HCV antibody-positive (n = 1533). Individuals with spontaneous clearance (18%, n = 276) were excluded. Among the remaining 1257 HCV antibody-positive participants (mean age 42, 71% male), 29% were Aboriginal. At enrolment, the majority reported recent injecting (60%) and non-injecting drug use (87%). Between January 1998 and March 2010, 6% (77 of 1257) initiated HCV treatment. In adjusted analyses, Aboriginal ethnicity [adjusted odds ratio (AOR) 0.23; 95% CI 0.10, 0.51] and crack cocaine use (AOR 0.61; 95% CI 0.37, 0.99) were associated with a decreased odds of receiving HCV treatment, while methamphetamine injecting (AOR 0.16; 95% CI 0.02, 1.18) trended towards a lower odds of receiving treatment. HCV treatment uptake ranged from 0.2 (95% CI 0.0, 0.7) per 100 person-years (PYs) in 2003 to 1.6 (95% CI 0.9, 2.6) per 100 PYs in 2009. CONCLUSION: HCV treatment uptake remains low in this large community-based cohort of inner city residents with a high HCV prevalence and access to universal healthcare.

Establishing a community-based participatory research partnership among people who use drugs in Ottawa: the PROUD cohort study.

BACKGROUND: Grounded in a community-based participatory research (CBPR) framework, the PROUD (Participatory Research in Ottawa: Understanding Drugs) Study aims to better understand HIV risk and prevalence among people who use drugs in Ottawa, Ontario. The purpose of this paper is to describe the establishment of the PROUD research partnership. METHODS: PROUD relies on peers' expertise stemming from their lived experience with drug use to guide all aspects of this CBPR project. A Community Advisory Committee (CAC), comprised of eight people with lived experience, three allies and three ex-officio members, has been meeting since May 2012 to oversee all aspects of the project. Eleven medical students from the University of Ottawa were recruited to work alongside the committee. Training was provided on CBPR; HIV and harm reduction; and administering HIV point-of-care (POC) tests so that the CAC can play a key role in research design, data collection, analysis, and knowledge translation activities. RESULTS: From March-December 2013, the study enrolled 858 participants who use drugs (defined as anyone who has injected or smoked drugs other than marijuana in the last 12 months) into a prospective cohort study. Participants completed a one-time questionnaire administered by a trained peer or medical student, who then administered an HIV POC test. Recruitment, interviews and testing occurred in both the fixed research site and various community settings across Ottawa. With consent, prospective follow-up will occur through linkages to health care records available through the Institute for Clinical and Evaluation Sciences. CONCLUSION: The PROUD Study meaningfully engaged the communities of people who use drugs in Ottawa through the formation of the CAC, the training of peers as community-based researchers, and integrated KTE throughout the research project. This project successfully supported skill development across the team and empowered people with drug use experience to take on leadership roles, ensuring that this research process will promote change at the local level. The CBPR methods developed in this study provide important insights for future research projects with people who use drugs in other settings.

Occupational stigma as a primary barrier to health care for street-based sex workers in Canada.

Individuals working in the sex industry continue to experience many negative health outcomes. As such, disentangling the factors shaping poor health access remains a critical public health priority. Within a quasi-criminalised prostitution environment, this study aimed to evaluate the prevalence of occupational stigma associated with sex work and its relationship to barriers to accessing health services. Analyses draw on baseline questionnaire data from a community-based cohort of women in street-based sex work in Vancouver, Canada (2006-2008). Of a total of 252 women, 141 (55.9%) reported occupational sex work stigma (defined as hiding occupational sex work status from family, friends and/or home community), while 125 (49.6%) reported barriers to accessing health services in the previous six months. In multivariable analysis, adjusting for sociodemographic, interpersonal and work environment risks, occupational sex work stigma remained independently associated with an elevated likelihood of experiencing barriers to health access. Study findings indicate the critical need for policy and societal shifts in views of sex work as a legitimate occupation, combined with improved access to innovative, accessible and non-judgmental health care delivery models for street-based sex workers that include the direct involvement of sex workers in development and implementation.

The role of diet in predicting iron deficiency anemia in HIV-positive women.

PURPOSE: The association between medical, social, and nutritional factors and iron deficiency anemia was examined in adult women who had tested positive for human immunodeficiency virus (HIV) and were living in the Greater Vancouver Area. METHODS: This was a cross-sectional observational study of 102 HIV-positive women, aged 19 or older, who were patients of one of three chosen community health clinics in Vancouver, British Columbia. Information on usual dietary intake and other nutrition-related factors was collected with a short diet survey, while medical information and laboratory data were obtained from each participant's medical chart. RESULTS: Of the predictors studied, a CD4 cell count below 200 cells/µL, a regular menstrual pattern, and African ethnicity were associated with an increased risk of iron deficiency anemia. Dietary intake was not independently associated with iron status. CONCLUSIONS: Iron deficiency anemia in HIV-positive women has multifactorial and complicated causation, but is strongly associated with poorer immune status and greater menstrual losses. Health disparities in Aboriginal and African women may lead to a higher risk for iron deficiency anemia. Routine screening and ongoing nutrition education are necessary for the prevention and management of iron deficiency anemia. Further research into factors associated with iron deficiency anemia is essential to improve prevention and management efforts.

A dose-response relationship between exposure to a large-scale HIV preventive intervention and consistent condom use with different sexual partners of female sex workers in southern India.

BACKGROUND: The Avahan Initiative, a large-scale HIV preventive intervention targeted to high-risk populations including female sex workers (FSWs), was initiated in 2003 in six high-prevalence states in India, including Karnataka. This study assessed if intervention exposure was associated with condom use with FSWs' sexual partners, including a dose-response relationship. METHODS: Data were from a cross-sectional study (2006-07) of 775 FSWs in three districts in Karnataka. Survey methods accounted for the complex cluster sampling design. Bivariate and multivariable logistic regression was used to separately model the relationships between each of five intervention exposure variables and five outcomes for consistent condom use (CCU= always versus frequently/sometimes/never) with different sex partners, including with: all clients; occasional clients; most recent repeat client; most recent non-paying partner; and the husband or cohabiting partner. Linear tests for trends were conducted for three continuous intervention exposure variables. RESULTS: FSWs reported highest CCU with all clients (81.7%); CCU was lowest with FSWs' husband or cohabiting partner (9.6%). In multivariable analysis, the odds of CCU with all clients and with occasional clients were 6.3-fold [95% confidence intervals, CIs: 2.8-14.5] and 2.3-fold [95% CIs: 1.4-4.1] higher among FSWs contacted by intervention staff and 4.9-fold [95% CIs: 2.6-9.3] and 2.3-fold [95% CIs: 1.3-4.1] higher among those who ever observed a condom demonstration by staff, respectively, compared to those who had not. A significant dose-response relationship existed between each of these CCU outcomes and increased duration since first contacted by staff (P=0.001; P=0.006) and numbers of condom demonstrations witnessed (P=0.004; P=0.026); a dose-response relationship was also observed between condom use with all clients and number of times contacted by staff (P=0.047). Intervention exposure was not associated with higher odds of CCU with the most recent repeat client, most recent non-paying partner or with the husband or cohabiting partner. CONCLUSION: Study findings suggest that exposure to a large-scale HIV intervention for FSWs was associated with increased CCU with commercial clients. Moreover, there were dose-response relationships between CCU with clients and increased duration since first contacted by staff, times contacted by staff and number of condom demonstrations. Additional program effort is required to increase condom use with non-commercial partners.

Factors associated with numbers of client partners of female sex workers across five districts in South India.

BACKGROUND: This study investigated the structural-environmental and individual-level social factors associated with the numbers of commercial sex clients of female sex workers (FSWs) per month (CPM). METHODS: Data were analyzed from cross-sectional surveys of FSWs in 5 districts in Karnataka state, India (2004-2005). Bivariate and multivariable negative binomial regression models with generalized estimating equations were constructed for each district. Normalized weights were used to account for complex sampling design. RESULTS: Median (average) CPM varied significantly (P < 0.001) across districts, from 40.0 (56.9) CPM in the district with the highest immunodeficiency virus prevalence (33.9%) to 16.0 (26.1) in the district with the lowest prevalence (9.7%). In multivariable analysis, there was a significant positive association between rates of CPM and sex work as sole income in 4 districts (adjusted incidence rate ratios, AIRR: [95% confidence intervals]: AIRR: 1.3 [1.0-1.7], P < 0.005-1.7 [1.2-2.5], P < 0.01); age, typology (place of solicitation), and marital status were significantly associated with CPM in 3 districts, with an inverse association between age and CPM (P < 0.01). FSWs soliciting clients in brothels had higher rates of CPM than home-based FSWs in 2 districts (AIRR: 1.5 [1.1-2.0]-1.6 [1.0-2.7], P < 0.05), whereas public places-based FSWs had higher rates in 1 district (AIRR: 1.4 [1.1-1.8], P < 0.01); cohabiting FSWs had higher rates than married FSWs in 3 districts, whereas single FSWs had higher rates in one district. CONCLUSIONS: These results provide support for the continued development of structural core group interventions that address common elements of sex work placing FSWs at higher risk for immunodeficiency virus, as well as geographically focused programs that account for local differences in sexual structure.

Determinants of hospitalization for a cutaneous injection-related infection among injection drug users: a cohort study.

BACKGROUND: Cutaneous injection-related infections (CIRI) are a primary reason individuals who inject drugs (IDU) are hospitalized. The objective of this study was to investigate determinants of hospitalization for a CIRI or related infectious complication among a cohort of supervised injection facility (SIF) users. METHODS: From 1 January 1 2004 until 31 January 2008, using Cox proportional hazard regression, we examined determinants of hospitalization for a CIRI or related infectious complication (based on ICD 10 codes) among 1083 IDU recruited from within the SIF. Length of stay in hospital and cost estimates, based on a fully-allocated costing model, was also evaluated. RESULTS: Among hospital admissions, 49% were due to a CIRI or related infectious complication. The incidence density for hospitalization for a CIRI or related infectious complication was 6.07 per 100 person-years (95% confidence intervals [CI]: 4.96 - 7.36). In the adjusted Cox proportional hazard model, being HIV positive (adjusted hazard ratio [AHR] = 1.79 [95% CI: 1.17 - 2.76]) and being referred to the hospital by a nurse at the SIF (AHR = 5.49 [95% CI: 3.48 - 8.67]) were associated with increased hospitalization. Length of stay in hospital was significantly shorter among participants referred to the hospital by a nurse at the SIF when compared to those who were not referred (4 days [interquartile range {IQR}: 2-7] versus 12 days [IQR: 5-33]) even after adjustment for confounders (p = 0.001). CONCLUSIONS: A strong predictor of hospitalization for a CIRI or related infectious complication was being referred to the hospital by a nurse from the SIF. This finding indicates that nurses not only facilitate hospital utilization but may provide early intervention that prevents lengthy and expensive hospital visits for a CIRI or related infectious complication.

Challenges in initiating antiretroviral therapy in 2010.

Many clinical trials have shown that initiating antiretroviral therapy (ART) at higher rather than lower CD4 T cell-positive counts results in survival benefit. Early treatment can help prevent end-organ damage associated with HIV replication and can decrease infectivity. The mainstay of treatment is either a non-nucleoside reverse transcriptase inhibitor or a ritonavir-boosted protease inhibitor in combination with two nucleoside reverse transcriptase inhibitors. While effective at combating HIV, ART can produce adverse alterations of lipid parameters, with some studies suggesting a relationship between some anti-retroviral agents and cardiovascular disease. As the HIV-positive population ages, issues such as hypertension and diabetes must be taken into account when initiating ART. Adhering to ART can be difficult; however, nonoptimal adherence to ART can result in the development of resistance; thus, drug characteristics and the patient's preparedness to begin therapy must be considered. Reducing the pill burden through the use of fixed-dose antiretroviral drug combinations can facilitate adherence.

De nombreux essais cliniques ont montré que l'instauration d'un traitement antirétroviral à partir d'un seuil de CD4 T supérieur plutôt qu'inférieur produit un avantage sur la survie. Un traitement précoce peut aider à prévenir l'atteinte des organes cibles associée à la réplication du VIH et réduire l'infectivité. Le traitement repose principalement soit sur un inhibiteur non nucléosidique de la transcriptase inverse, soit sur un inhibiteur de la protéase rehaussé par ritonavir en association avec deux inhibiteurs nucléosidiques de la transcriptase inverse. Bien qu'efficaces pour combattre le VIH, les antirétroviraux peuvent avoir une influence négative sur les paramètres lipidiques, des études ayant fait état d'un lien entre certains antirétroviraux et la maladie cardiovasculaire. À mesure que la population VIH-positive vieillit, il faut tenir compte de problèmes comme l'hypertension et le diabète au moment d'amorcer des antirétroviraux. La fidélité aux antirétroviraux pose parfois problème. Toutefois, une piètre observance thérapeutique peut contribuer à la résistance. Il faut donc prendre en compte les caractéristiques des patients et leur volonté de démarrer le traitement. On peut réduire le nombre de comprimés en utilisant des antirétroviraux d'association à dose fixe afin de promouvoir l'observance thérapeutique.

Concurrent Hepatitis C and B Virus and Human Immunodeficiency Virus Infections Are Associated With Higher Mortality Risk Illustrating the Impact of Syndemics on Health Outcomes.

BACKGROUND: Hepatitis C virus (HCV), hepatitis B virus (HBV), and human immunodeficiency virus (HIV) infections are associated with significant mortality globally and in North America. However, data on impact of concurrent multiple infections on mortality risk are limited. We evaluated the effect of HCV, HBV, and HIV infections and coinfections and associated factors on all-cause mortality in British Columbia (BC), Canada. METHODS: The BC Hepatitis Testers Cohort includes ~1.7 million individuals tested for HCV or HIV, or reported as a case of HCV, HIV, or HBV from 1990 to 2015, linked to administrative databases. We followed people with HCV, HBV, or HIV monoinfection, coinfections, and triple infections from their negative status to date of death or December 31, 2016. Extended Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with all-cause mortality. RESULTS: Of 658 704 individuals tested for HCV, HBV, and HIV, there were 33 804 (5.13%) deaths. In multivariable Cox regression analysis, individuals with HCV/HBV/HIV (HR, 8.9; 95% CI, 8.2-9.7) infections had the highest risk of mortality followed by HCV/HIV (HR, 4.8; 95% CI, 4.4-5.1), HBV/HIV (HR, 4.1; 95% CI, 3.5-4.8), HCV/HBV (HR, 3.9; 95% CI, 3.7-4.2), HCV (HR, 2.6; 95% CI, 2.6-2.7), HBV (HR, 2.2; 95% CI, 2.0-2.3), and HIV (HR, 1.6; 95% CI, 1.5-1.7). Additional factors associated with mortality included injection drug use, problematic alcohol use, material deprivation, diabetes, chronic kidney disease, heart failure, and hypertension. CONCLUSIONS: Concurrent multiple infections are associated with high mortality risk. Substance use, comorbidities, and material disadvantage were significantly associated with mortality independent of coinfection. Preventive interventions, including harm reduction combined with coinfection treatments, can significantly reduce mortality.

Structural and environmental barriers to condom use negotiation with clients among female sex workers: implications for HIV-prevention strategies and policy.

OBJECTIVES: We investigated the relationship between environmental-structural factors and condom-use negotiation with clients among female sex workers. METHODS: We used baseline data from a 2006 Vancouver, British Columbia, community-based cohort of female sex workers, to map the clustering of "hot spots" for being pressured into unprotected sexual intercourse by a client and assess sexual HIV risk. We used multivariate logistic modeling to estimate the relationship between environmental-structural factors and being pressured by a client into unprotected sexual intercourse. RESULTS: In multivariate analyses, being pressured into having unprotected sexual intercourse was independently associated with having an individual zoning restriction (odds ratio [OR] = 3.39; 95% confidence interval [CI] = 1.00, 9.36), working away from main streets because of policing (OR = 3.01; 95% CI = 1.39, 7.44), borrowing a used crack pipe (OR = 2.51; 95% CI = 1.06, 2.49), client-perpetrated violence (OR = 2.08; 95% CI = 1.06, 4.49), and servicing clients in cars or in public spaces (OR = 2.00; 95% CI = 1.65, 5.73). CONCLUSIONS: Given growing global concern surrounding the failings of prohibitive sex-work legislation on sex workers' health and safety, there is urgent need for environmental-structural HIV-prevention efforts that facilitate sex workers' ability to negotiate condom use in safer sex-work environments and criminalize abuse by clients and third parties.

Unstable housing and hepatitis C incidence among injection drug users in a Canadian setting.

BACKGROUND: There has emerged growing recognition of the link between housing and health. Since Vancouver, Canada has had increasing concerns with homelessness brought about by urban renewal in the lead-up to the 2010 Winter Olympic Games, we evaluated hepatitis C virus (HCV) incidence among injection drug users (IDU) with and without stable housing. METHODS: Data were derived from a collaboration between two prospective cohort studies of IDU in Vancouver, Canada. Using Cox Proportional Hazards regression, we compared HCV incidence among participants with and without stable housing, and determined independent predictors of HCV incidence. RESULTS: Overall, 3074 individuals were recruited between May 1996 and July 2007, among whom 2541 (82.7%) were baseline HCV-infected. Among the 533 (17.3%) individuals who were not HCV-infected at baseline, 147 tested HCV antibody-positive during follow-up, for an incidence density of 16.89 (95% confidence interval: 14.76 - 19.32) per 100 person-years. In a multivariate Cox regression model, unstable housing remained independently associated with HCV infection (relative hazard = 1.47 (1.02 - 2.13). CONCLUSION: HCV prevalence and incidence are high in this setting and were associated with unstable housing. Efforts to protect existing low-income housing and improve access to housing may help to reduce HCV incidence.

HIV/AIDS in Vancouver, British Columbia: a growing epidemic.

The prevalence of HIV in Vancouver, British Columbia was subject to two distinct periods of rapid increase. The first occurred in the 1980s due to high incidence among men who have sex with men (MSM), and the second occurred in the 1990s due to high incidence among injection drug users (IDU). The purpose of this study was to estimate and model the trends in HIV prevalence in Vancouver from 1980 to 2006. HIV prevalence data were entered into the UNAIDS/WHO Estimation and Projection Package (EPP) where prevalence trends were estimated by fitting an epidemiological model to the data. Epidemic curves were fit for IDU, MSM, street-based female sex trade workers (FSW), and the general population. Using EPP, these curves were then aggregated to produce a model of Vancouver's overall HIV prevalence. Of the 505 000 people over the age of 15 that reside in Vancouver, 6108 (ranging from 4979 to 7237) were living with HIV in the year 2006, giving an overall prevalence of 1.21 percent (ranging from 0.99 to 1.43 percent). The subgroups of IDU and MSM account for the greatest proportion of HIV infections. Our model estimates that the prevalence of HIV in Vancouver is greater than one percent, roughly 6 times higher than Canada's national prevalence. These results suggest that HIV infection is having a relatively large impact in Vancouver and that evidence-based prevention and harm reduction strategies should be expanded.

Burden of HIV infection among aboriginal injection drug users in Vancouver, British Columbia.

OBJECTIVES: We sought to examine whether there were differential rates of HIV incidence among Aboriginal and non-Aboriginal injection drug users in a Canadian setting. METHODS: Data were derived from 2 prospective cohort studies of injection drug users in Vancouver, British Columbia. Using the Kaplan-Meier method and Cox proportional hazards regression, we compared HIV incidence among Aboriginal and non-Aboriginal participants. RESULTS: Overall, 2496 individuals were recruited between May 1996 and December 2005. Compared with that of non-Aboriginal persons, the baseline HIV prevalence was higher among Aboriginal persons (16.0% vs 25.1%; P<.001). Among participants who were HIV negative at baseline, the cumulative HIV incidence at 48 months was higher among Aboriginal persons (18.5% vs 9.5%; P<.001). In multivariate analyses, Aboriginal ethnicity was independently associated with elevated HIV incidence (relative hazard=1.59; 95% confidence interval=1.12, 2.26; P=.009). CONCLUSIONS: Aboriginal persons in Vancouver had a significantly elevated burden of HIV infection, which calls for a culturally sensitive and evidence-based response. Policymakers in other settings with at-risk Aboriginal populations should seek to avert similar public health emergencies by being proactive with evidence-based HIV-prevention programs.

Barriers associated with the treatment of hepatitis C virus infection among illicit drug users.

BACKGROUND: Illicit drug users account for the majority of cases of HCV infection in the developed world, but few have received treatment. METHODS: We evaluated barriers to initiating HCV treatment -- including general treatment willingness -- and factors associated with these among HCV infected illicit drug users. Participants were recruited via convenience sampling from two community clinics in Canada. Individuals age >18 years with a history of illicit drug use completed interviewer-administered surveys. Those reporting positive HCV testing underwent additional questioning on willingness, uptake and barriers to treatment for HCV. RESULTS: Of 188 HCV positive illicit drug users, 16% (n=30) had received treatment for HCV. Factors associated with a decreased treatment uptake included current heroin use and HIV/HCV co-infection. Among those not having received therapy, 77% (117/153) indicated a willingness to receive HCV treatment. Factors associated with treatment willingness included not being infected with HIV, having not recently used drugs by injection and having reported physical health problems. Among those not having sought HCV treatment (n=107), the major reasons for not doing so were: lack of information about HCV or knowledge that treatment was available (23%), the absence of symptoms (20%) and the perceived side effects of treatment (14%). CONCLUSIONS: Among illicit drug users attending inner city clinics, we have observed a low uptake of HCV treatment, but a high willingness to receive therapy. An increased focus on improving education about the long-term consequences of HCV and the availability of effective treatment are important components for expanding HCV treatment among illicit drug users.

Social and structural violence and power relations in mitigating HIV risk of drug-using women in survival sex work.

High rates of violence among street-level sex workers have been described across the globe, while in cities across Canada the disappearance and victimization of drug-using women in survival sex work is ongoing. Given the pervasive levels of violence faced by sex workers over the last decades, and extensive harm reduction and HIV prevention efforts operating in Vancouver, Canada, this research aimed to explore the role of social and structural violence and power relations in shaping the HIV risk environment and prevention practices of women in survival sex work. Through a participatory-action research project, a series of focus group discussions were conceptualized and co-facilitated by sex workers, community and research partners with a total of 46 women in early 2006. Based on thematic, content and theoretical analysis, the following key factors were seen to both directly and indirectly mediate women's agency and access to resources, and ability to practice HIV prevention and harm reduction: at the micro-level, boyfriends as pimps and the 'everyday violence' of bad dates; at the meso-level, a lack of safe places to take dates, and adverse impacts of local policing; and at the macro-level, dopesickness and the need to sell sex for drugs. Analysis of the narratives and daily lived experiences of women sex workers highlight the urgent need for a renewed HIV prevention strategy that moves beyond a solely individual-level focus to structural and environmental interventions, including legal reforms, that facilitate 'enabling environments' for HIV prevention.

Preliminary development of a scale to measure stigma relating to sexually transmitted infections among women in a high risk neighbourhood.

BACKGROUND: As stigma is a socially constructed concept, it would follow that stigma related to sexual behaviours and sexually transmitted infections would carry with it many of the gender-based morals that are entrenched in social constructs of sexuality. In many societies, women tend to be judged more harshly with respect to sexual morals, and would therefore have a different experience of stigma related to sexual behaviours as compared to men. While a variety of stigma scales exist for sexually transmitted infections (STIs) in general; none incorporate these female-specific aspects. The objective of this study was to develop a scale to measure the unique experience of STI-related stigma among women. METHODS: A pool of items was identified from qualitative and quantitative literature on sexual behaviour and STIs among women. Women attending a social evening program at a local community health clinic in a low-income neighbourhood with high prevalence of substance use were passively recruited to take part in a cross-sectional structured interview, including questions on sexual behaviour, sexual health and STI-related stigma. Exploratory factor analysis was used to identify stigma scales, and descriptive statistics were used to assess the associations of demographics, sexual and drug-related risk behaviours with the emerging scales. RESULTS: Three scales emerged from exploratory factor analysis--female-specific moral stigma, social stigma (judgement by others) and internal stigma (self-judgement)--with alpha co-efficients of 0.737, 0.705 and 0.729, respectively. In this population of women, internal stigma and social stigma carried higher scores than female-specific moral stigma. Aboriginal ethnicity was associated with higher internal and female-specific moral stigma scores, while older age (>30 years) was associated with higher female-specific moral stigma scores. CONCLUSION: Descriptive statistics indicated an important influence of culture and age on specific types of stigma. Quantitative researchers examining STI-stigma should consider incorporating these female-specific factors in order to tailor scales for women.

Risk factors for developing a cutaneous injection-related infection among injection drug users: a cohort study.

BACKGROUND: Cutaneous injection-related infections (CIRI), such as abscesses and cellulitis, are common and preventable among injection drug users (IDU). However, risk factors for CIRI have not been well described in the literature. We sought to characterize the risk factors for current CIRI among individuals who use North America's first supervised injection facility (SIF). METHODS: A longitudinal analysis of factors associated with developing a CIRI among participants enrolled in the Scientific Evaluation of Supervised Injecting (SEOSI) cohort between January 1, 2004 and December 31, 2005 was conducted using generalized linear mixed-effects modelling. RESULTS: In total, 1065 participants were eligible for this study. The proportion of participants with a CIRI remained under 10% during the study period. In a multivariate generalized linear mixed-effects model, female sex (Adjusted Odds Ratio (AOR) = 1.68 [95% Confidence Interval (CI): 1.16-2.43]), unstable housing (AOR = 1.49 [95% CI: 1.10-2.03]), borrowing a used syringe (AOR = 1.60 [95% CI: 1.03-2.48]), requiring help injecting (AOR = 1.42 [95% CI: 1.03-1.94]), and injecting cocaine daily (AOR = 1.41 [95% CI: 1.02-1.95]) were associated with an increased risk of having a CIRI. CONCLUSION: CIRI were common among a subset of IDU in this study, including females, those injecting cocaine daily, living in unstable housing, requiring help injecting or borrowing syringes. In order to reduce the burden of morbidity associated with CIRI, targeted interventions that address a range of factors, including social and environmental conditions, are needed.

Demographics, sexual risk behaviours and uptake of screening for sexually transmitted infections among attendees of a weekly women-only community clinic program.

OBJECTIVES: Vancouver's DTES represents a high-risk neighbourhood, in which there exist a number of community clinics and outreach programs. The purpose of this study was twofold: 1) to describe the population of women attending a weekly women's program with respect to demographics, risk behaviours and prevalence of STI, and 2) to assess the uptake of STI screening in this setting. METHODS: A cross-sectional survey was undertaken during a weekly community clinic-based women's program from October to December, 2004. Women were recruited at the start of the program each week and were invited to provide urine samples for chlamydia and gonorrhea screening. RESULTS: Among 126 respondents, the median age was 42 (36-49), more than half (52%) self-identified as White and 40% as Aboriginal ethnicity. Forty percent were currently involved in the sex trade. Two thirds reported a Pap smear in the past year, while 14% had not accessed sexual health care (Pap smear, STI or HIV testing). Among the 92/126 (74%) women providing a urine sample, the prevalence of chlamydia and gonorrhea was 2.2% and 0.0%, respectively. CONCLUSION: The majority of women accessing this program were over 35 years of age, and while nearly half were currently involved in the sex trade, cross-sectional screening did not reveal a substantial prevalence of STIs. Women who were not regular program attendees reported less sexual health care, and represented the only two cases of chlamydia found. Innovative programs that better serve the needs of populations that remain unable or unwilling to seek sexual health care in its current formats are needed.