RESUMEN
INTRODUCTION: Although the health and community benefits of supervised injection facilities are well documented, little is known about long-term patterns of utilization of this form of health service. The present study seeks to longitudinally characterize discontinuation of use of a supervised injection facility in Vancouver, Canada. METHODS: Data were drawn from 2 community-recruited prospective cohorts of people who inject drugs between December 2005 and December 2016. In 2018, extended Cox regression for recurrent events was used to examine factors associated with time to cessation of supervised injection facility use during periods of active injection. RESULTS: Of 1,336 people who inject drugs that were followed for a median of 50 months, 847 (63.4%) participants reported 1,663 6-month periods of supervised injection facility use cessation while actively injecting drugs (incidence density of 26.6 events per 100 person-years). An additional 2,282 (57.8%) of the total 3,945 6-month periods of supervised injection facility use cessation occurred during periods of injection cessation. In multivariable analyses, enrollment in methadone maintenance therapy (adjusted hazard ratio=1.41) and HIV seropositivity (adjusted hazard ratio=1.23) were positively associated with supervised injection facility use cessation during periods of active injection, whereas homelessness (adjusted hazard ratio=0.59), at least daily heroin injection (adjusted hazard ratio=0.70), binge injection (adjusted hazard ratio=0.68), public injection (adjusted hazard ratio=0.67), nonfatal overdose (adjusted hazard ratio=0.73), difficulty accessing addiction treatment (adjusted hazard ratio=0.69), and incarceration (adjusted hazard ratio=0.70) were inversely associated with this outcome (all p<0.05). The most commonly reported reasons for supervised injection facility use cessation were injection drug use cessation (42.3%) and a preference for injecting at home (30.7%). CONCLUSIONS: These findings suggest that this supervised injection facility successfully retains people who inject drugs at elevated risk of drug-related harms and indicate that many supervised injection facility clients neither use this service nor inject drugs perpetually.
Asunto(s)
Sobredosis de Droga/prevención & control , Programas de Intercambio de Agujas/estadística & datos numéricos , Tratamiento de Sustitución de Opiáceos/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Abuso de Sustancias por Vía Intravenosa/terapia , Adulto , Canadá , Sobredosis de Droga/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tratamiento de Sustitución de Opiáceos/métodos , Estudios Prospectivos , Abuso de Sustancias por Vía Intravenosa/complicacionesRESUMEN
OBJECTIVES: Although previous cross-sectional studies have identified correlates of detectable plasma HIV-1 RNA viral load (VL) among HIV-positive people who use drugs (PWUD), longitudinal factors associated with heightened HIV transmission potential have not been well described. Therefore, we longitudinally examined factors associated with amount of person-time spent above log10(1500) copies/ml plasma among HIV-positive PWUD in Vancouver, Canada. DESIGN: Data were derived from a long-running prospective cohort of HIV-positive PWUD linked to comprehensive clinical records including systematic VL monitoring. METHODS: We used generalized estimating equations modeling to longitudinally examine factors associated with person-time (in days) with a VL more than log10(1500) copies/ml plasma in the previous 180 days. RESULTS: Between December 2005 and May 2014, 845 PWUD were eligible and included in the study. Participants spent an average of 26.8% of observation time with a VL more than log10(1500) copies/ml. In multivariable analyses, homelessness (Adjusted Rate Ratio [ARR]â=â1.45) and lack of social support (ARRâ=â1.27) were positively associated with person-time with a VL more than log10(1500) copies/ml. Older age (ARRâ=â0.97) and enrolment in addiction treatment (ARRâ=â0.75) were negatively associated with the outcome in multivariable analyses (all Pâ<â0.05). CONCLUSION: Social and structural factors, including periods of homelessness or lacking in social support, were independently associated with greater amount of time with heightened HIV transmission potential. These findings suggest the need for targeted efforts to address modifiable contextual factors that contribute to increased risk of onward HIV transmission among PWUD.
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Consumidores de Drogas , Infecciones por VIH/virología , VIH-1/aislamiento & purificación , ARN Viral/sangre , Trastornos Relacionados con Sustancias/complicaciones , Carga Viral , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Canadá , Femenino , Humanos , Drogas Ilícitas , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Apoyo Social , Factores Socioeconómicos , Factores de Tiempo , Adulto JovenRESUMEN
INTRODUCTION: Socioeconomically marginalized people who use illicit drugs (PWUD) often engage in alternative income generating activities to meet their basic needs. These activities commonly carry a number of health and social risks, which may prompt some PWUD to consider addiction treatment to reduce their drug use or drug-related expenses. We sought to determine whether engaging in certain forms of income generation was independently associated with self-reported need for addiction treatment among a cohort of PWUD in Vancouver, Canada. METHODS: Data from two prospective cohorts of PWUD in Vancouver were used in generalized estimating equations to identify factors associated with self-reported need for addiction treatment, with a focus on income generating activities. RESULTS: Between June 2013 and May 2014, 1285 respondents participated in the study of whom 483 (34.1%) were female and 396 (30.8%) indicated that they needed addiction treatment. In final multivariate analyses, key factors significantly and positively associated with self-reported need for addiction treatment included engaging in illegal income generating activities (adjusted odds ratio [AOR]=1.96, 95% confidence interval [CI}: 1.11-3.46); sex work (AOR=1.61, 95% CI: 1.05-2.47), homelessness (AOR=1.65, 95% CI: 1.22-2.25); and recent engagement in counselling (AOR=1.85, 95% CI: 1.40-2.44). DISCUSSION: Our results suggest that key markers of socioeconomic marginalization are strongly linked with a stated need for addiction treatment. These findings underscore the need to provide appropriate and accessible addiction treatment access to marginalized PWUD and to consider alternative approaches to reduce socioeconomic disadvantage.
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Crimen/psicología , Crimen/estadística & datos numéricos , Renta , Trabajo Sexual/estadística & datos numéricos , Trastornos Relacionados con Sustancias/psicología , Trastornos Relacionados con Sustancias/terapia , Adulto , Canadá , Femenino , Personas con Mala Vivienda/estadística & datos numéricos , Humanos , Drogas Ilícitas , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Asunción de Riesgos , Trabajo Sexual/psicología , Trastornos Relacionados con Sustancias/economíaRESUMEN
OBJECTIVE: Given that people who use illicit drugs (PWUD) often engage in prohibited income generation to support their basic needs, we sought to examine the role of these activities in shaping antiretroviral therapy (ART) adherence and plasma HIV RNA-1 viral load suppression among HIV-infected PWUD. DESIGN: Longitudinal analyses among HIV-positive, ART-exposed PWUD in the AIDS Care Cohort to evaluate Exposure to Survival Services prospective cohort study (2005-2013). METHODS: Generalized linear mixed-effects and mediation analyses examined the relationship between prohibited income generation (e.g., sex work, drug dealing, theft, street-based income) and virologic suppression (plasma viral load ≤50 copies/ml plasma) adjusting for adherence and potential confounders. RESULTS: Among 687 HIV-infected PWUD, 391 (56.9%) individuals reported prohibited income generation activity during the study period. In multivariate analyses, prohibited income generation remained independently and negatively associated with virologic suppression (adjusted odds ratio: 0.68, 95% confidence interval: 0.52-0.88) following adjustment for hypothesized confounders, including high-intensity drug use, ART adherence and homelessness. Although partially mediated by ART adherence, the relationship between prohibited income generation and virologic suppression was maintained in mediation analyses (Sobel statistic =â-1.95, P = 0.05). CONCLUSION: Involvement in prohibited income generation decreases the likelihood of virologic suppression directly and indirectly through its negative association with ART adherence. These findings suggest that linkages between socioeconomic marginalization, the criminalization of illicit drug use, and insufficient employment opportunities may produce barriers to access and retention in care. Programmatic and policy interventions that decrease socioeconomic vulnerability may therefore reduce HIV-related morbidity, mortality, and onward transmission.
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Antirretrovirales/administración & dosificación , Infecciones por VIH/tratamiento farmacológico , VIH-1/aislamiento & purificación , Cumplimiento de la Medicación , Marginación Social , Trastornos Relacionados con Sustancias/complicaciones , Carga Viral , Adulto , Canadá , Femenino , Humanos , Drogas Ilícitas , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Plasma/virología , Estudios Prospectivos , ARN Viral/sangre , Trastornos Relacionados con Sustancias/psicologíaRESUMEN
OBJECTIVE: Many people who use illicit drugs (PWUD) face challenges to their financial stability. Resulting activities that PWUD undertake to generate income may increase their vulnerability to violence. We therefore examined the relationship between income generation and exposure to violence across a wide range of income generating activities among HIV-positive and HIV-negative PWUD living in Vancouver, Canada. METHODS: Data were derived from cohorts of HIV-seropositive and HIV-seronegative PWUD (n=1876) between December 2005 and November 2012. We estimated the relationship between different types of income generation and suffering physical or sexual violence using bivariate and multivariate generalised estimating equations, as well as the characteristics of violent interactions. RESULTS: Exposure to violence was reported among 977 (52%) study participants over the study period. In multivariate models controlling for sociodemographic characteristics, mental health status, and drug use patterns, violence was independently and positively associated with participation in street-based income generation activities (ie, recycling, squeegeeing and panhandling; adjusted OR (AOR)=1.39, 95% CI 1.23 to 1.57), sex work (AOR=1.23, 95% CI 1.00 to 1.50), drug dealing (AOR=1.63, 95% CI 1.44 to 1.84), and theft and other acquisitive criminal activity (AOR=1.51, 95% CI 1.27 to 1.80). Engagement in regular, self-employment or temporary employment was not associated with being exposed to violence. Strangers were the most common perpetrators of violence (46.7%) and beatings the most common type of exposure (70.8%). CONCLUSIONS: These results suggest that economic activities expose individuals to contexts associated with social and structural vulnerability to violence. The creation of safe economic opportunities which can minimise vulnerability to violence among PWUD is therefore urgently required.
Asunto(s)
Consumidores de Drogas/estadística & datos numéricos , Seropositividad para VIH/economía , Abuso de Sustancias por Vía Intravenosa/economía , Violencia/economía , Adulto , Análisis de Varianza , Colombia Británica/epidemiología , Comorbilidad , Víctimas de Crimen/economía , Víctimas de Crimen/psicología , Víctimas de Crimen/estadística & datos numéricos , Consumidores de Drogas/psicología , Femenino , Seronegatividad para VIH , Seropositividad para VIH/epidemiología , Seropositividad para VIH/psicología , Humanos , Drogas Ilícitas/economía , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Prospectivos , Asunción de Riesgos , Trabajadores Sexuales , Abuso de Sustancias por Vía Intravenosa/epidemiología , Abuso de Sustancias por Vía Intravenosa/psicología , Violencia/psicología , Violencia/estadística & datos numéricosRESUMEN
OBJECTIVE: Given the link between employment and mortality in the general population, we sought to assess this relationship among HIV-positive people who use illicit drugs in Vancouver, Canada. METHODS: Data were derived from a prospective cohort study of HIV seropositive people who use illicit drugs (n=666) during the period of May 1996-June 2010 linked to comprehensive clinical data in Vancouver, Canada, a setting where HIV care is delivered without charge. We estimated the relationship between employment and mortality using proportional hazards survival analysis, adjusting for relevant behavioural, clinical, social and socioeconomic factors. RESULTS: In a multivariate survival model, a time-updated measure of full time, temporary or self-employment compared with no employment was significantly associated with a lower risk of death (adjusted HR=0.44, 95% CI 0.22 to 0.91). Results were robust to adjustment for relevant confounders, including age, injection and non-injection drug use, plasma viral load and baseline CD4 T-cell count. CONCLUSIONS: These findings suggest that employment may be an important dimension of mortality risk of HIV-seropositive illicit drug users. The potentially health-promoting impacts of labour market involvement warrant further exploration given the widespread barriers to employment and persistently elevated levels of preventable mortality among this highly marginalised population.