Sex work as an emerging risk factor for HIV seroconversion among people who inject drugs in the SurvUDI network

Abstract : BACKGROUND: Recent analyses have shown an emerging positive association between sex work and human immunodeficiency virus (HIV) incidence among people who inject drugs (PWIDs) in the SurvUDI network. METHODS: Participants who had injected in the past 6 months were recruited across the Province of Quebec and in the city of Ottawa, mainly in harm reduction programs. They completed a questionnaire and provided gingival exudate for HIV antibody testing. The associations with HIV seroconversion were tested with a Cox proportional hazard model using time-dependent covariables including the main variable of interest, sexual activity (sex work; no sex work; sexually inactive). The final model included significant variables and confounders of the associations with sexual activity. RESULTS: Seventy-two HIV seroconversions were observed during 5239.2 person-years (py) of follow-up (incidence rates: total = 1.4/100 py; 95% confidence interval [CI], 1.1-1.7; sex work = 2.5/100 py; 95% CI, 1.5-3.6; no sex work = 0.8/100 py; 95% CI, 0.5-1.2; sexually inactive = 1.8/100 py; 95% CI, 1.1-2.5). In the final multivariate model, HIV incidence was significantly associated with sexual activity (sex work: adjusted hazard ratio [AHR], 2.19; 95% CI, 1.13-4.25; sexually inactive: AHR, 1.62; 95% CI, 0.92-2.88), and injection with a needle/syringe used by someone else (AHR, 2.84; 95% CI, 1.73-4.66). CONCLUSIONS: Sex work is independently associated with HIV incidence among PWIDs. At the other end of the spectrum of sexual activity, sexually inactive PWIDs have a higher HIV incidence rate, likely due to more profound dependence leading to increased vulnerabilities, which may include mental illness, poverty, and social exclusion. Further studies are needed to understand whether the association between sex work and HIV is related to sexual transmission or other vulnerability factors

Estimating the size of the population of persons who inject drugs in the island of Montréal, Canada, using a six-source capture-recapture model

BACKGROUND: To plan and implement services to persons who inject drugs (PWID), knowing their number is essential. For the island of Montréal, Canada, the only estimate, of 11,700 PWID, was obtained in 1996 through a capture-recapture method. Thirteen years later, this study was undertaken to produce a new estimate. METHODS: PWID were defined as individuals aged 14-65 years, having injected recently and living on the island of Montréal. The study period was 07/01/2009 to 06/30/2010. An estimate was produced using a six-source capture-recapture log-linear regression method. The data sources were two epidemiological studies and four drug dependence treatment centres. Model selection was conducted in two steps, the first focusing on interactions between sources and the second, on age group and gender as covariates and as modulators of interactions. RESULTS: A total of 1480 PWID were identified in the six capture sources. They corresponded to 1132 different individuals. Based on the best-fitting model, which included age group and sex as covariates and six two-source interactions (some modulated by age), the estimated population was 3910 PWID (95% confidence intervals (CI): 3180-4900) which represents a prevalence of 2.8 (95% CI: 2.3-3.5) PWID per 1000 persons aged 14-65 years. CONCLUSIONS: The 2009-2010 estimate represents a two-third reduction compared to the one for 1996. The multisource capture-recapture method is useful to produce estimates of the size of the PWID population. It is of particular interest when conducted at regular intervals thus allowing for close monitoring of the injection phenomenon

Changing patterns of first injection across key periods of the French Harm Reduction Policy: PrimInject, a cross sectional analysis

Background: Monitoring of emerging modes of drug consumption in France has identified new patterns of injection among youths with diverse social backgrounds, which may explain the persistence of high rates of hepatitis C virus infection. The circumstances surrounding the first injection have been poorly documented in the group of heavy drug users and in the context of the French opioid substitution treatment (OST) policy that provides expanded access to high-dosage buprenorphine (BHD). Methods: An Internet survey (Priminject) was conducted from October 2010 to March 2011 with French drug users. Four time periods were compared based on critical dates throughout the implementation of the Harm Reduction Policy in France. Results: Compared with drug users who injected for the first time prior to 1995, the aspects of drug use for users who recently injected for the first time were as follows: (1) experimentation with miscellaneous drugs before the first injection; (2) an older age at the time of first injection; (3) heroin as the drug of choice for an individual’s first injection, notwithstanding the increased usage of stimulant drugs; (4) BHD did not appear to be a pathway to injection; and (5) an increased number of users who injected their first time alone, without the help or presence of another individual. Conclusion: The PrimInject study showed that there is a group of injection drug users that is larger than the group of injection drug users observed in previous studies; therefore, it is necessary to diversify programs to reach the entire spectrum of high-risk users

Risk factors associated with unsafe injection practices at the first injection episode among intravenous drug users in France : results from PrimInject, an Internet survey

Abstract : Background. New drug use patterns may increase the risk of human immunodeficiency virus and hepatitis infections. In France, new injection patterns among youths with diverse social backgrounds have emerged, which may explain the persistently high rates of hepatitis C virus infection. This study explores factors associated with injection risk behaviours at first injection among users who began injecting in the post-2000 era. Methods. A cross-sectional study was conducted on the Internet from October 2010 to March 2011, through an online questionnaire. Multivariate logistic regression identified the independent correlates of needle sharing and equipment (cooker/cotton filter) sharing. Results. Among the 262 respondents (mean age 25 years), 65% were male. Both risk behaviours were positively associated with initiation before 18 years of age (aOR 3.7 CI 95% 1.3–10.6 and aOR 3.0 CI 95% 1.3–7.0) and being injected by another person (aOR 3.1 CI 95% 1.0–9.9 and aOR 3.0 CI 95% 1.3–7.1). Initiation at a party was an independent correlate of equipment sharing (aOR 2.6 95% CI 1.0–6.8). Conclusions. Results suggest a need for innovative harm reduction programmes targeting a variety of settings and populations, including youths and diverse party scenes. Education of current injectors to protect both themselves and those they might initiate into injection is critically important

Hepatitis C Virus seroconversion among persons who inject drugs in relation to primary care physician visiting: The potential role of primary healthcare in a combined approach to Hepatitis C prevention

BACKGROUND: Meaningful reductions in Hepatitis C Virus (HCV) transmission rates among persons who inject drugs (PWID) require a comprehensive prevention approach, including access to harm reduction measures and to healthcare-related interventions, such as HCV screening, testing and antiviral treatment. Little is known, however, about the role of visiting a primary care physician (PCP) in relation to HCV infection risk among PWID, when integrated within a combined prevention approach. This study assessed the association between PCP visiting and HCV seroconversion among PWID attending needle exchange programs (NEP). METHODS: A prospective cohort study, HEPCO, was conducted among active PWID in Montréal (2004-2013). Interviews scheduled at 3- or 6-month intervals included completion of an interviewer-administered questionnaire, and collection of blood samples for HCV antibody testing. HCV-seronegative participants who reported NEP attendance at baseline and had at least one follow-up visit were eligible for this study. HCV incidence was calculated using the person-time method. Time-varying Cox regression modeling was conducted to evaluate the relationship between self-reported recent PCP visiting and HCV incidence. RESULTS: At baseline assessment, of 226 participants (80.5% male; median age: 30.6 years), 37.2% reported having recently visited a PCP. During 449.6 person-years of follow-up, 79 participants seroconverted to HCV [incidence rate: 17.6 per 100 person-years, 95% confidence interval (CI): 14.0-21.8]. Covariate-adjusted analyses indicated that visiting a PCP was associated with a lower risk of HCV infection [Adjusted Hazard Ratio: 0.54, 95% CI: 0.31-0.93]. Other independent predictors of HCV infection included unstable housing, cocaine injection and prescription opioid injection. CONCLUSION: Among PWID attending NEP, visiting a PCP was associated with a lower risk of HCV infection. Yet, only a minority of participants reported PCP visiting. Efforts to intensify engagement with PCP among PWID could potentially contribute to lower HCV transmission when integrated within a combined approach to prevention

Exploration of a crack use setting and its impact on drug users' risky drug use and sexual behaviors : the case of piaules in a Montréal neighborhood.

Abstract : From July 2011, a one-year study based on ethnographic methodology was carried out in “crack houses” in the neighborhood of Hochelaga-Maisonneuve in Montréal, Canada. The study aimed to explore the operational style of a specific indoor drug use setting and its impact on users’ risky sexual and drug use behaviors in a context of drug market change. A thematic analysis of observational and interview notes was conducted. This study stresses the importance to examine the role of environmental factors in relation to crack smoking’s health-related risks and to complement individual-based interventions with structural strategies. The study’s limitations are noted

Are poker players all the same? : latent class analysis

Poker is the gambling game that is currently gaining the most in popularity. However, there is little information on poker players' characteristics and risk factors. Furthermore, the first studies described poker players, often recruited in universities, as an homogeneous group who played in only one of the modes (land based or on the Internet). This study aims to identify, through latent class analyses, poker player subgroups. A convenience sample of 258 adult poker players was recruited across Quebec during special events or through advertising in various media. Participants filled out a series of questionnaires (Canadian Problem Gambling Index, Beck Depression, Beck Anxiety, erroneous belief and alcohol/drug consumption). The latent class analysis suggests that there are three classes of poker players. Class I (recreational poker players) includes those who have the lowest probability of engaging intensively in different game modes. Participants in class II (Internet poker players) all play poker on the Internet. This class includes the highest proportion of players who consider themselves experts or professionals. They make a living in part or in whole from poker. Class III (multiform players) includes participants with the broadest variety of poker patterns. This group is complex: these players are positioned halfway between professional and recreational players. Results indicate that poker players are not an homogeneous group identified simply on the basis of the form of poker played. The specific characteristics associated with each subgroup points to vulnerabilities that could potentially be targeted for preventive interventions

Residential trajectories of street youth--the Montréal cohort study

Little is known about the course of homelessness among youth between the ages of 18 and 25 despite the many characteristics distinguishing them from adolescents and from older street-involved populations. We examined the residential trajectories of homeless young adults in Montréal over a 21-month period and identified determinants of various trajectory profiles. The 365 study participants (79 % men, mean age 21.9 years) were followed for an average of 515 days (range 81–630 days). We assessed housing status with a questionnaire based on the residential follow-back calendar designed by the New Hampshire Dartmouth Research Center. Using latent growth analysis to examine achievement of residential stability over time, we observed three different trajectories: group 1 presented a low probability of housing throughout the entire study period; group 2 showed a high probability of early and stable housing; group 3 displayed a fluctuating pattern. Protective correlates of residential stability included high school education, birth in Canada, and presence of mental health problems. Drug abuse or dependence was associated with a decreased probability of housing

La crise chez les joueurs de jeux de hasard et d’argent : au-delà de l’appel de détresse, les services novateurs qui y répondent

La dynamique des joueurs excessifs a souvent pour conséquence d’affecter les relations affectives, l’emploi, la santé financière de la famille de même que la santé mentale et physique de la personne. Ces multiples répercussions personnelles et professionnelles accentuent la détresse déjà très importante chez les joueurs. Or, la détresse conjuguée à de multiples petits événements stressants crée un terrain propice à l’émergence d’une multitude de crises psychosociales. À partir d’une recension des écrits, cet article présentera d’abord les liens complexes entre la crise et le jeu. Ensuite, une présentation critique des différents services de crise pour les joueurs (lignes d’écoute, services d’intervention de crise dans les casinos et service d’autoexclusion) sera effectuée. Enfin, nous conclurons par des recommandations pour améliorer les services actuels.The dynamic of pathological gamblers often impacts their affective relationships, employment and the family’s financial health, as well as the person’s mental and physical health. These multiple personal and professional repercussions accentuate the gambler’s already significant distress. This distress, combined with many little stressful incidents, creates a fertile ground for the emergence of multiple psychosocial crises. Based on the documentation, this article begins by presenting the complex relationship between the crisis and gambling, followed by a critical presentation of the various crisis services for gamblers (hotlines, crisis intervention services in the casinos and self-exclusion service). Lastly, recommendations on how to improve current services are made.La dinámica de los jugadores excesivos afecta a menudo como consecuencia las relaciones afectivas, el empleo, la salud financiera de la familia y la salud mental y física de la persona. Estas múltiples repercusiones personales y profesionales acentúan el desamparo, que es ya muy importante en los jugadores. Ahora bien, el desamparo conjugado con múltiples pequeños acontecimientos estresantes crea un terreno propicio para el surgimiento de una cantidad de crisis psicosociales. A partir de una revisión de textos, este artículo presentará en primer lugar los vínculos complejos entre la crisis y el juego. Continuará luego con la presentación crítica de los diferentes servicios de crisis para jugadores (líneas de escucha, servicios de intervención de crisis en los casinos y servicio de auto-exclusión). Finalmente, concluirá con recomendaciones destinadas a mejorar los servicios actuales

Patterns of cocaine and opioid co-use and polyroutes of administration among street-based cocaine users in Montréal, Canada

Background: Effective public health programs aimed at problematic cocaine users are challenged by the fact that they can have complex patterns of drug use with respect to polysubstance use and routes of drug administration. This study was carried out to explore the presence of subgroups of cocaine users on the basis of their concurrent use of opioids and their routes of cocaine and opioid administration, and to determine if subgroups could be differentiated in terms of sociodemographic factors and risk behaviours. Methods: Regular cocaine users (≥ 1 per week) were recruited in low-threshold services located in the Montréal downtown area. The following variables were examined: demographic characteristics, types of drug used, routes of drug administration, and condom use with occasional or commercial sexual partners. Latent class analysis and multinomial logistic regression modeling were carried out. Results: 886 cocaine users were recruited (83.5% male: mean age 35.38 years). A 5-class model was identified: 1) “Cocaine Smokers” (CSs) (n = 161; membership probability (MP) = 0.183); 2) “Cocaine Smokers/Sniffers” (CSSs) (n = 201; MP = 0.218); “Cocaine Injectors” (CIs) (n = 207; MP = 0.231); 4) “Cocaine-Opioid Injectors” (COIs) (n = 277; MP = 0.291); and 5) “Cocaine-Opioid Polyroute users” (COPs) (n = 40; MP = 0.077). Compared with COIs, other subtypes were significantly different in terms of either age, duration of cocaine use, ethnic background, homelessness, polydrug use or condom use. Conclusion: The heterogeneity of consumption patterns supports the importance of offering an array of interventions aimed at problematic cocaine users. These should include the provision of clean injecting and smoking material, the promotion of safe sexual behaviours and the prevention of initiation to drug injection. In the absence of specific treatment, cocaine users should have access to primary health care services and addiction treatment based on innovative behavioral and pharmacological approaches