Population-based rates, timing and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa: a multi-country prospective cohort study

BackgroundModelled mortality estimates have been useful for health programmes in low-income and middle-income countries. However, these estimates are often based on sparse and low-quality data. We aimed to generate high quality data about the burden, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa.MethodsIn this prospective cohort study done in 11 community-based research sites in south Asia and sub-Saharan Africa, between July, 2012, and February, 2016, we conducted population-based surveillance of women of reproductive age (15–49 years) to identify pregnancies, which were followed up to birth and 42 days post partum. We used standard operating procedures, data collection instruments, training, and standardisation to harmonise study implementation across sites. Verbal autopsies were done for deaths of all women of reproductive age, neonatal deaths, and stillbirths. Physicians used standardised methods for cause of death assignment. Site-specific rates and proportions were pooled at the regional level using a meta-analysis approach.FindingsWe identified 278 186 pregnancies and 263 563 births across the study sites, with outcomes ascertained for 269 630 (96·9%) pregnancies, including 8761 (3·2%) that ended in miscarriage or abortion. Maternal mortality ratios in sub-Saharan Africa (351 per 100 000 livebirths, 95% CI 168–732) were similar to those in south Asia (336 per 100 000 livebirths, 247–458), with far greater variability within sites in sub-Saharan Africa. Stillbirth and neonatal mortality rates were approximately two times higher in sites in south Asia than in sub-Saharan Africa (stillbirths: 35·1 per 1000 births, 95% CI 28·5–43·1 vs 17·1 per 1000 births, 12·5–25·8; neonatal mortality: 43·0 per 1000 livebirths, 39·0–47·3 vs 20·1 per 1000 livebirths, 14·6–27·6). 40–45% of pregnancy-related deaths, stillbirths, and neonatal deaths occurred during labour, delivery, and the 24 h postpartum period in both regions. Obstetric haemorrhage, non-obstetric complications, hypertensive disorders of pregnancy, and pregnancy-related infections accounted for more than three-quarters of maternal deaths and stillbirths. The most common causes of neonatal deaths were perinatal asphyxia (40%, 95% CI 39–42, in south Asia; 34%, 32–36, in sub-Saharan Africa) and severe neonatal infections (35%, 34–36, in south Asia; 37%, 34–39 in sub-Saharan Africa), followed by complications of preterm birth (19%, 18–20, in south Asia; 24%, 22–26 in sub-Saharan Africa).InterpretationThese results will contribute to improved global estimates of rates, timing, and causes of maternal and newborn deaths and stillbirths. Our findings imply that programmes in sub-Saharan Africa and south Asia need to further intensify their efforts to reduce mortality rates, which continue to be high. The focus on improving the quality of maternal intrapartum care and immediate newborn care must be further enhanced. Efforts to address perinatal asphyxia and newborn infections, as well as preterm birth, are critical to achieving survival goals in the Sustainable Development Goals era

A scoping review and thematic analysis of social and behavioural research among HIV-serodiscordant couples in high-income settings.

CAPRISA, 2015.Abstract available in pdf

Socioeconomic marginalization and overdose : implications for upstream approaches for overdose prevention during a prolonged public health emergency

Background: Canada and the United States are in the midst of an escalating overdose crisis. While poverty and socioeconomic disadvantage are increasingly recognized as important contributors to drug-related harm, their precise role in overdose remains understudied. This dissertation sought to: synthesize evidence regarding the pathways and mechanisms linking socioeconomic elements to overdose outcomes; examine the relationship between a comprehensive range of socioeconomic indicators and non-fatal overdose; identify and characterize gender-stratified profiles of socioeconomic exposures in men and women who use drugs; and, finally, determine whether these gender-stratified profiles predict non-fatal overdose. Methods: Data from Chapter 2 came from a realist review of research published between 2004 and 2019. Data for Chapters 3-5 cover the time period between 2014 and 2018 and are from two community-recruited prospective cohort studies of people who use drugs (PWUD) in Vancouver, Canada. A range of longitudinal analytic techniques were used, including: generalized linear mixed-effect models, repeated measures latent class analyses, and generalized estimating equations. Results: Findings from the realist review identified eight overlapping socioeconomic dimensions with documented linkages to overdose outcomes through material, normative, and bio-psychosocial pathways. In Chapter 3, across the total sample of PWUD from Vancouver, homelessness, lower material security, and participation in informal and illegal income generating activities were independently and positively associated with non-fatal overdose. In Chapter 4, gender-stratified analyses revealed that men and women experienced mutually reinforcing and overlapping socioeconomic exposures characterized by variations in income, material and housing security, participation in informal or illegal income generation, criminal justice involvement, and police contact. Gendered profiles of increasing socioeconomic disadvantage aligned with high-intensity drug use patterns (e.g., opioids and stimulants) and a range of health-related outcomes (e.g., HCV). In Chapter 5, exposure to multiple increasing dimensions of socioeconomic disadvantage was found to be independently associated with greater likelihood of experiencing non-fatal overdose in both men and women. Conclusions: Socioeconomic determinants are key drivers of overdose risk. To address the socioeconomic production of overdose risk, findings point to the urgent need to expand upstream and multilevel programs and policies, including inclusive, gender-informed health and social welfare programming, and broader drug policy reform.Graduate and Postdoctoral StudiesGraduat

Supervised injection facilities in Canada: past, present, and future

Canada has long contended with harms arising from injection drug use. In response to epidemics of HIV infection and overdose in Vancouver in the mid-1990s, a range of actors advocated for the creation of supervised injection facilities (SIFs), and after several unsanctioned SIFs operated briefly and closed, Canada’s first sanctioned SIF opened in 2003. However, while a large body of evidence highlights the successes of this SIF in reducing the health and social harms associated with injection drug use, extraordinary efforts were needed to preserve it, and continued activism by local people who inject drugs (PWID) and healthcare providers was needed to promote further innovation and address gaps in SIF service delivery. A growing acceptance of SIFs and increasing concern about overdose have since prompted a rapid escalation in efforts to establish SIFs in cities across Canada. While much progress has been made in that regard, there is a pressing need to create a more enabling environment for SIFs through amendment of federal legislation. Further innovation in SIF programming should also be encouraged through the creation of SIFs that accommodate assisted injecting, the inhalation of drugs. As well, peer-run, mobile, and hospital-based SIFs also constitute next steps needed to optimize the impact of this form of harm reduction intervention.Medicine, Faculty ofOther UBCNon UBCMedicine, Department ofPopulation and Public Health (SPPH), School ofReviewedFacult

Acceptability and design preferences of supervised injection services among people who inject drugs in a mid-sized Canadian City

Background: Supervised injection services (SIS) have been shown to reduce the public- and individual-level harms associated with injection drug use. While SIS feasibility research has been conducted in large urban centres, little is known about the acceptability of these services among people who inject drugs (PWID) in mid-sized cities. We assessed the prevalence and correlates of willingness to use SIS as well as design and operational preferences among PWID in London, Canada. Methods: Between March and April 2016, peer research associates administered a cross-sectional survey to PWID in London. Socio-demographic characteristics, drug-use patterns, and behaviours associated with willingness to use SIS were estimated using bivariable and multivariable logistic regression models. Chi-square tests were used to compare characteristics with expected frequency of SIS use among those willing to use SIS. Design and operational preferences are also described. Results: Of 197 PWID included in this analysis (median age, 39; interquartile range (IQR), 33–50; 38% female), 170 (86%) reported willingness to use SIS. In multivariable analyses, being female (adjusted odds ratio (AOR) 0.29; 95% confidence interval (CI) 0.11–0.75) was negatively associated with willingness to use, while public injecting in the last 6 months (AOR 2.76; 95% CI 1.00–7.62) was positively associated with willingness to use. Participants living in unstable housing, those injecting in public, and those injecting opioids and crystal methamphetamine daily reported higher expected frequency of SIS use (p < 0.05). A majority preferred private cubicles for injecting spaces and daytime operational hours, while just under half preferred PWID involved in service operations. Conclusions: High levels of willingness to use SIS were found among PWID in this setting, suggesting that these services may play a role in addressing the harms associated with injection drug use. To maximize the uptake of SIS, programme planners and policy makers should consider the effects of gender and views of PWID regarding SIS design and operational preferences.Medicine, Faculty ofOther UBCNon UBCReviewedFacult

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.Graduate and Postdoctoral StudiesMedicine, Faculty ofOther UBCNon UBCMedicine, Department ofReviewedFacult

Assessing the temporality between transitions onto opioid agonist therapy and engagement with antiretroviral therapy in a cohort of HIV-positive people who use opioids daily

A robust evidence-base describes the beneficial association between opioid agonist therapy (OAT) and HIV-related outcomes among people living with HIV and opioid use disorder. While some evidence suggests the stabilizing effect of OAT on antiretroviral therapy (ART) treatment engagement, less is understood about the potential for an inverse relationship. We sought to examine the relationship between transitions in ART engagement and transitions onto OAT. We used data from a prospective cohort of people living with HIV who use drugs in Vancouver, Canada — a setting with no-cost access to ART and low or no-cost access to OAT among low-income residents. Restricting the sample to those who reported daily or greater opioid use, we used generalized linear mixed-effects models to estimate the relationships between our primary outcome of transitions onto OAT (methadone or buprenorphine/naloxone) and transitions 1) onto ART and 2) into ART adherence. Subsequent analyses assessed the temporal sequencing of transitions. Between 2005 and 2017, among 433 participants, 48.3% reported transitioning onto OAT at least once. In concurrent analyses, transitions onto ART were positively and significantly associated with transitions onto OAT. Temporal sequencing revealed that transitions into OAT were also positively and significantly associated with subsequent transitions onto ART. OAT’s potential to facilitate the uptake of ART points to the continued need to scale-up low-threshold, client-centered substance use services integrated alongside HIV care.Arts, Faculty ofGraduate and Postdoctoral StudiesMedicine, Faculty ofNon UBCMedicine, Department ofSociology, Department ofReviewedFacultyResearcherGraduat

HIV/STI prevention interventions: A systematic review and meta-analysis

Behavioral interventions can prevent the transmission of HIV and sexually transmitted infections. This systematic review and meta-analysis assesses the effectiveness and quality of available evidence of HIV prevention interventions for people living with HIV in high-income settings. Searches were conducted in MEDLINE, EMBASE, PsycINFO, and CDC Compendium of Effective Interventions. Interventions published between January, 1998 and September, 2015 were included. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Forty-six articles and 63 datasets involving 14,096 individuals met inclusion criteria. Included articles were grouped by intervention type, comparison group and outcome. Few of these had high or moderate quality of evidence and statistically significant effects. One intervention type, group-level health education interventions, were effective in reducing HIV/STI incidence when compared to attention controls. A second intervention type, comprehensive risk counseling and services, was effective in reducing sexual risk behaviors when compared to both active and attention controls. All other intervention types showed no statistically significant effect or had low or very low quality of evidence. Given that the majority of interventions produced low or very low quality of evidence, researchers should commit to rigorous evaluation and high quality reporting of HIV intervention studies

Examining the associations between HIV-related stigma and health outcomes in people living with HIV/AIDS: A series of meta-analyses

From publisher: Objective: To conduct a systematic review and series of meta-analyses on the association between HIV-related stigma and health among people living with HIV. Data sources: A structured search was conducted on 6 electronic databases for journal articles reporting associations between HIV-related stigma and health- related outcomes published between 1996 and 2013. Study eligibility criteria: Controlled studies, cohort studies, case-control studies and cross-sectional studies in people living with HIV were considered for inclusion. Outcome measures: Mental health (depressive symptoms, emotional and mental distress, anxiety), quality of life, physical health, social support, adherence to antiretroviral therapy, access to and usage of health/ social services and risk behaviours. Results: 64 studies were included in our meta-analyses. We found significant associations between HIV-related stigma and higher rates of depression, lower social support and lower levels of adherence to antiretroviral medications and access to and usage of health and social services. Weaker relationships were observed between HIV-related stigma and anxiety, quality of life, physical health, emotional and mental distress and sexual risk practices. While risk of bias assessments revealed overall good quality related to how HIV stigma and health outcomes were measured on the included studies, high risk of bias among individual studies was observed in terms of appropriate control for potential confounders. Additional research should focus on elucidating the mechanisms behind the negative relationship between stigma and health to better inform interventions to reduce the impact of stigma on the health and well-being of people with HIV. Conclusions: This systematic review and series of meta-analyses support the notion that HIV-related stigma has a detrimental impact on a variety of health- related outcomes in people with HIV. This review can inform the development of multifaceted, intersectoral interventions to reduce the impact of HIV-related stigma on the health and well-being of people living with HIV.This work was supported by a Knowledge Synthesis grant from the Canadian Institutes of Health Research, and in-kind contributions provided by the Ontario HIV Treatment Network