Dual Sexual and Drug-related Predictors of Hepatitis C Incidence among Sex Workers in a Canadian Setting: Gaps and Opportunities for Scale-up of Hepatitis C Virus Prevention, Treatment, and Care

Background  Hepatitis C virus (HCV) represents a significant cause of morbidity and mortality globally. While sex workers may face elevated HCV risks through both drug and sexual pathways, incidence data among sex workers are severely lacking. HCV incidence and predictors of HCV seroconversion among women sex workers in Vancouver, BC were characterized in this study. Methods  Questionnaire and serological data were drawn from a community-based cohort of women sex workers (2010–2014). Kaplan–Meier methods and Cox regression were used to model HCV incidence and predictors of time to HCV seroconversion. Results  Among 759 sex workers, HCV prevalence was 42.7%. Among 292 baseline-seronegative sex workers, HCV incidence density was 3.84/100 person-years (PY), with higher rates among women using injection drugs (23.30/100 PY) and non-injection crack (6.27/100 PY), and those living with HIV (13.27/100 PY) or acute sexually transmitted infections (STIs) (5.10/100 PY). In Cox analyses adjusted for injection drug use, age (hazard ratio (HR) 0.94, 95% confidence interval (CI) 0.86–1.01), acute STI (HR 2.49, 95% CI 1.02–6.06), and non-injection crack use (HR 2.71, 95% CI 1.18–6.25) predicted time to HCV seroconversion. Discussion  While HCV incidence was highest among women who inject drugs, STIs and the use of non-injection stimulants appear to be pathways to HCV infection, suggesting potential dual sexual/drug transmission. Integrated HCV services within sexual health and HIV/STI programs are recommended

Gaps in the Hepatitis C Continuum of Care among Sex Workers in Vancouver, British Columbia: Implications for Voluntary Hepatitis C Virus Testing, Treatment and Care

BACKGROUND: Hepatitis C virus (HCV) eradication leads to reduced morbidity, mortality and transmission. Despite the disproportionate burden of HCV among sex workers, data regarding the HCV care continuum in this population remain negligible. METHODS: Using baseline data from an ongoing cohort of women sex workers in Vancouver (An Evaluation of Sex Workers’ Health Access, January 2010 to August 2013), the authors assessed HCV prevalence and engagement in the HCV care continuum within the past year. Multivariable logistic regression analyses were used to evaluate associations with recent (ie, in the past year) HCV testing. RESULTS: Among 705 sex workers, 302 (42.8%) were HCV seropositive. Of these, 22.5% were previously unaware of their HCV status, 41.7% had accessed HCV-related care, 13.9% were offered treatment and only 1.0% received treatment. Among 552 HCV-seronegative sex workers, only one-half (52.9%) reported a recent HCV test. In multivariable analysis, women who self-identified as a sexual/gender minority (adjusted OR [aOR] 1.89 [95% CI 1.11 to 3.24]), resided in the inner city drug use epicentre (aOR 3.19 [95%CI 1.78 to 5.73]) and used injection (aOR 2.00 [95% CI 1.19 to 3.34]) or noninjection drugs (aOR 1.95 [95% CI 1.00 to 3.78]) had increased odds of undergoing a recent HCV test, while immigrant participants (aOR 0.24 [95% CI 0.12 to 0.48]) had decreased odds. CONCLUSIONS: Despite a high burden of HCV among sex workers, large gaps in the HCV care continuum remain. Particularly concerning are the low access to HCV testing, with one-fifth of women living with HCV being previously unaware of their status, and the exceptionally low prevalence of HCV treatment. There is a critical need for further research to better understand and address barriers to engage in the HCV continuum for sex workers

Adjunctive Corticosteroid Therapy Decreases Lung Permeability in Patients with AIDS-Related Pneumocystis carinii Pneumonia

OBJECTIVE: To assess the effect of adjunctive corticosteroid therapy on lung permeability as measured by Tc-DTPA lung clearance scan in patients with AIDS-related Pneumocystis carinii pneumonia (PCP)

Structural barriers to antiretroviral therapy among sex workers living with HIV : Findings of a longitudinal study in Vancouver, Canada

In light of limited data on structural determinants of access and retention in antiretroviral therapy (ART) among sex workers, we examined structural correlates of ART use among sex workers living with HIV over time. Longitudinal data were drawn from a cohort of 646 female sex workers in Vancouver, Canada (2010–2012) and linked pharmacy records on ART dispensation. We used logistic regression with generalized estimating equations (GEE) to examine correlates of gaps in ART use (i.e., treatment interruptions or delayed ART initiation), among sex workers living with HIV (n=74). Over a 2.5-year period, 37.8% of participants experienced gaps in ART use (i.e., no ART dispensed in a six-month period). In a multivariable GEE model, younger age, migration/mobility, incarceration, and non-injection drug use independently correlated with gaps in ART use. In spite of successes scaling-up ART in British Columbia, younger, mobile, or incarcerated sex workers face persistent gaps in access and retention irrespective of drug use. Community-based, tailored interventions to scale-up entry and retention in ART for sex workers should be further explored in this setting.Medicine, Faculty ofOther UBCNon UBCMedicine, Department ofReviewedFacultyResearche

Gender differences in access to methadone maintenance therapy in a Canadian setting

Introduction and Aims: Methadone maintenance therapy (MMT) is an evidence-based treatment for opioid addiction. While gender differences in MMT pharmacokinetics, drug use patterns and clinical profiles have been previously described, few studies have compared rates of MMT use among community-recruited samples of persons who inject drugs (IDU). Design and Methods: The present study used prospective cohorts of IDU followed between May 1996 and May 2013 in Vancouver, British Columbia, Canada. We investigated potential factors associated with time to methadone initiation using Cox proportional hazards modeling. Stratified analyses were used to examine for gender differences in rates of MMT enrolment. Results: Overall, 1848 baseline methadone naïve IDU were included in the study, among whom 595 (32%) were female. In an adjusted model, male gender was independently associated with increased time to MMT initiation and an overall lower rate of enrolment (adjusted relative hazard (ARH) = 0.74 [95% confidence interval [CI]: 0.65-0.85]). Among both female and male IDU, Caucasian ethnicity and daily injection heroin use were associated with decreased time to methadone initiation, while in females pregnancy was also associated with more rapid initiation. Discussion and Conclusions: These data highlight gender differences in methadone use among a population of community-recruited IDU. While factors associated with methadone use were similar between genders, rates of use were lower among male IDU, highlighting the need to consider gender when designing strategies to improve recruitment into MMT.Medicine, Faculty ofOther UBCMedicine, Department ofReviewedFacultyResearche

Patterns of heroin and cocaine injection and plasma HIV-1 RNA suppression among a long-term cohort of injection drug users

Background Previous studies suggest that active drug use may compromise HIV treatment among HIV-positive injection drug users (IDU). However, little is known about the differential impacts of cocaine injection, heroin injection, and combined cocaine and heroin injection on plasma HIV-1 RNA suppression. Methods Data were derived from a longstanding open prospective cohort of HIV-positive IDU in Vancouver, Canada. Kaplan-Meier methods and Cox proportional hazards regression were used to examine the impacts of different drug use patterns on rates of plasma HIV-1 RNA suppression. Results Between May 1996 and April 2008, 267 antiretroviral (ART) naïve participants were seen for a median follow-up duration of 50.6 months after initiating ART. The incidence density of HIV-1 RNA suppression was 65.2 (95%CI: 57.0–74.2) per 100 person-years. In Kaplan-Meier analyses, compared to those who abstained from injecting, individuals injecting heroin, cocaine, or combined heroin/cocaine at baseline were significantly less likely to achieve viral suppression (all p 0.05). Conclusions Active injecting at the time of ART initiation was associated with lower plasma HIV-1 RNA suppression rates; however, there was no difference in suppression rates when drug use patterns were examined over time. These findings imply that adherence interventions for active injectors should optimally be applied at the time of ART initiation.Medicine, Faculty ofOther UBCNon UBCMedicine, Department ofPopulation and Public Health (SPPH), School ofReviewedFacultyResearcherGraduat

Prescription opioid injection among HIV-positive people who inject drugs in a Canadian setting

Prescription opioids (POs) are commonly prescribed to patients living with HIV/AIDS, while the illicit use of POs remains a major public health concern throughout Canada and the United States. We sought to identify the prevalence and correlates of PO injection among HIV-positive people who inject drugs (PWID) in Vancouver, Canada, where HIV/AIDS treatment and care is offered at no cost. We examined data from 634 individuals from an ongoing prospective cohort of HIV-positive PWID. Between December 2005 and November 2013, the median prevalence of recent PO injection was 24.2 % [interquartile range (IQR): 21.5–25.8 %]. In a multivariable generalized estimating equation model, Caucasian ethnicity, heroin injection, and drug dealing were positively associated with PO injection, while older age and methadone maintenance treatment were negatively associated with PO injection (all p < 0.05). Engagement on antiretroviral therapy was inversely associated with PO injection in a bivariable analysis, but did not remain significant after adjusting for heroin injection. These findings describe a particularly vulnerable sub-group of PWID who may benefit from targeted efforts to both minimize drug-related risk behaviors and support HIV/AIDS treatment.Medicine, Faculty ofOther UBCMedicine, Department ofReviewedFacultyResearcherGraduat

Improving Post-Release Care Engagement for People Living with HIV Involved in the Criminal Justice System: A Systematic Review.

Given sub-optimal HIV care outcomes for people living with HIV (PLWH) post-release from incarceration, we systematically searched peer-reviewed literature (2010-2021) describing controlled trial interventions aimed at improving Antiretroviral Therapy (ART) adherence and care linkage following release from correctional facilities for PLWH. Of 392 studies, 16 (4%) met the inclusion criteria. All studies were conducted in the United States and involved some form of intensive case management. Trials that scored highest in terms of study quality provided cell phones for engagement, reported sustained viral load suppression as a measurable outcome to infer ART adherence, and measured longitudinal data collected for at least 3-to-6 months following release. The two trials that demonstrated improved HIV viral load suppression involved Peer Navigators, and incentivized undetectable viral load, respectively. Facilitating support for addictions and addressing other social and structural barriers to achieving optimal health is also of vital importance in bridging care gaps for PLWH