Donald Sutherland

Factors associated with frequent needle exchange program attendance in injection drug users in Vancouver, Canada

The objective of this study was to identify factors associated with frequent needle exchange program (NEP) attendance by injection drug users (IDUs) in Vancouver, Canada. Data were examined from a case control study of recent HIV infection. IDUs with documented HIV seroconversion after January 1, 1994 (n = 89) and seronegative controls with two documented HIV-negative test results in the same period (n = 192) were asked about demographic and social information, drug injection and sexual behavior, and NEP attendance. Logistic regression was used to examine the effect of multiple variables on NEP attendance while adjusting for HIV status and other potential confounders. Frequent (> 1 time/week) versus nonfrequent (< or = 1 time/week) NEP attenders did not differ with respect to gender, age, ethnicity, education, or HIV serostatus. For men, multivariate analysis showed that frequent cocaine injection was the only variable independently associated with NEP attendance (adjusted odds ratio [AOR] = 3.9; 95% confidence interval [CI] = 1.8-8.3); for women, independently associated variables were frequency of any drug injection (AOR = 5.5; 95% CI = 1.7-17), shooting gallery attendance (AOR = 11.5; 95% CI = 2.2-66), and having a nonlegal source of income (AOR = 3.4; 95% CI = 1.0-12). Borrowing used needles was associated with frequent NEP attendance in the univariate analysis. The NEP in Vancouver attracts IDUs who are frequent injectors (especially men using cocaine) and who have high-risk behaviors or an unstable lifestyle. This finding reinforces the role of NEPs as potential focal points for intervention in this hard-to-reach population.

Estimating the size of hard-to-reach populations: a novel method using HIV testing data compared to other methods.

Objective: To estimate population size of hard-to-reach groups such as injecting drug users and men who have sex with men. Design: Several different methods were used to estimate the size of these populations in Canadas three largest cities (Toronto, Montreal and Vancouver). Methods: A novel method (referred to as the indirect method) was developed for use in Toronto and Vancouver that combines HIV serodiagnostic information with data on HIV testing behavior. Population size estimates were obtained by dividing the number of injecting drug users or men who have sex with men recorded in HIV serodiagnostic databases in a given year by the proportion of the corresponding group that reported being tested in a 1-year period. Results of this method were compared with four other methods: (1) population surveys; (2) capture-recapture (for injecting drug users only); (3) a modified Delphi technique; and (4) a method based on the proportion of never-married men aged 45 and over (for men who have sex with men only). Only these other methods were used in Montreal. Results: The survey method gave the lowest estimates which are best viewed as minimum estimates given the relative inability of surveys to access these populations and the reluctance of participants to admit to sensitive behaviors. The indirect method produced results more closely comparable with those obtained by other methods, but they are probably slight overestimates, at least for injecting drug users, due to possible underestimation of the proportion tested for HIV. Point estimates using the indirect method were 17 700 and 17 500 for injecting drug users in Toronto and Vancouver, respectively, and 39 100 and 15 900 for men who have sex with men. In Toronto, results for the other methods ranged from 12 300-13 360 for injecting drug users and 18 800-35 000 for men who have sex with men. For Vancouver, these ranges were 6400-11 670 and 7000-26 500, respectively. In Montreal, ranges were 4300-12 500 for injecting drug users and 18 500-40 000 for men who have sex with men. Conclusions: This novel method provides estimates of population size of hard-to-reach groups such as injecting drug users and men who have sex with men that are comparable with results derived by other methods. These estimates may be useful for the purposes of planning, implementing and evaluating prevention and care services, especially when they are combined with the results of other estimation methods to improve the degree of confidence in the resulting estimates.

The changing spectrum of AIDS index diseases in Canada

ObjectiveTo describe the changing spectrum of AIDS index diseases in Canada over a 10-year period from 1981 to 1991. DesignA descriptive, population-based study. SettingCanada. PatientsAll cases of AIDS in Canada reported by the Division of HIV/AIDS Epidemiology of the Department of National Health and Welfare. Main outcome measuresAge-standardized rates of initial AIDS manifestations (1987 Centers for Disease Control and Prevention case definition), by year of diagnosis among adults in Canada. ResultsA total of 6641 adult AIDS cases were examined. The rate of Pneumocystis carinii pneumonia (PCP) peaked in 1989 with a rate of 3.18 per 100000, declining to 2.74 per 100000 in 1991 (P= 0.894). Similarly, the rate of Kaposis sarcoma (KS) stabilized during this interval from 1.06 per 100 000 in 1987 to 1.14 per 100000 in 1991 (P=0.189). In contrast, the rates of all other AIDS-defining illnesses increased from 1.48 per 100 000 in 1987 to 3.43 per 100000 in 1991 (P= 0.001). For these other AIDS index diseases, significant rate increases were observed for esophageal candidiasis, cytomegalovirus (CMV) diseases, wasting syndrome, toxoplasmosis, and Mycobacterium avium complex (MAC) disease. ConclusionsOur study shows a leveling and decline in incidence of KS and PCP, respectively, and a concomitant increase of other diagnoses, especially esophageal candidiasis, CMV, wasting syndrome, toxoplasmosis, and MAC disease in Canada. These findings highlight the importance of developing specific strategies to prevent emerging AIDS index diseases and serve as a cautionary note to practicing clinicians, indicating the relative widening of the spectrum of HIV index diseases.

Factors associated with HIV testing among Canadians: results of a population-based survey

Summary: The purpose of this study was to examine the HIV-testing behaviour of Canadians aged 15 years and older. Questions on HIV testing were asked as part of a Canada-wide random digit dialling telephone survey conducted in December 1995 to January 1996 on health practices and attitudes toward health care in Canada ( n =3123). Including blood donation and insurance testing, 40.4% of men and 30.4% of women had been tested for HIV. Excluding blood donation and life-insurance testing (voluntary testing), 17.8% of men and 15.6% of women had been tested. In multivariate analyses, factors independently associated with voluntary testing among men were: having had sex with a man (OR=16.8), injection drug use (OR=5.8), having had a partner at high risk (OR=2.5), having received blood or clotting factor (OR=2.3), being younger than 45 years of age (OR=1.8), living in a city of over one million (OR=1.7), and making less than

Surveillance of HIV drug resistance transmission in Iran: experience gained from a pilot study

30,000 a year (OR=1.6). For women, factors independently associated with voluntary testing were having received blood or clotting factor (OR=3.9), having had a high-risk partner (OR= 3.5), being younger than 45 years of age (OR=2.4), having had sex with a man (OR=2.3), and being unattached (OR=2.0). Results indicated that those at risk are more likely to be tested. It is of concern, however, that many of those reporting risk factors have not been tested. A better understanding of HIV testing behaviour is needed to improve the planning and evaluation of prevention and counselling services.

HIV and Hepatitis C Virus Testing and Seropositivity Rates in Canadian Federal Penitentiaries: A Critical Opportunity for Care and Prevention

We performed a pilot surveillance study on transmitted HIV drug resistance (TDR) in Iran, with specimens collected and stored as dried blood spots (DBS). The protease region and relevant positions in the reverse transcriptase region of the pol gene were sequenced to detect mutations known to be associated with resistance to drugs in standard first-line regimens. Seventy-three specimens were collected, with 39 (53%) specimens yielding sequence from both protease and at least part of RT. Specimens were almost exclusively HIV-1 subtype CRF 35_A1D based on pol sequencing. Mutations were restricted to RT, with D67DG and V75AV each seen in a single specimen. An atypical protease inhibitor mutation, I47M, appeared at a resistance-associated position in protease from a single specimen. These preliminary data showed that the rate of transmitted drug resistance in Iran, within the areas sampled, was 5.1% (2/39). However, the small sample size makes this figure only an approximation. Due to the sampling strategy and resulting small sample size, we were unable to accurately calculate TDR rates for individual areas using the WHO HIV drug resistance threshold survey method. Increasing the sample size and improving the yield from DBS would improve the accuracy of drug resistance surveillance and facilitate wider application of this methodology in Iran.

Combining data sources to monitor the HIV epidemic in Canada.

BACKGROUND Incarcerated persons experience high rates of HIV and hepatitis C virus (HCV) infection, but little is known about the burden of these bloodborne viruses among federal penitentiary inmates in Canada. OBJECTIVE The present study investigates rates of testing and seropositivity for HIV and HCV among inmates in all 53 Canadian federal penitentiaries. METHODS A cross-sectional design using surveillance data on voluntary HIV and HCV antibody testing in 2002 were applied to estimate the rate of testing uptake and the rate of incident seropositive tests among new admissions to federal penitentiaries and resident inmates. Rates of testing and infection were further examined by sex and region. Seroprevalence of HIV and HCV was estimated from the number of cumulative positive tests to year-end. RESULTS Of 7670 new admissions during 2002, 30% were tested for HIV and HCV. Test seropositivity rates in this group were 0.7% for HIV and 10% for HCV. Of the 12,426 resident inmates, 28% were tested for HIV and 27% for HCV. Seropositivity rates in this group were 0.3% for HIV and 7% for HCV. Seroprevalence rates at yearend for 2002 were 2.0% for HIV and 26% for HCV and were substantially higher among women offenders (HIV: 3.7% of women, 1.9% of men; HCV: 34% of women, 26% of men). Variations in testing uptake and test seropositivity were observed across regions. CONCLUSIONS The present study underscores the value of continued monitoring and evaluation of trends in HIV and HCV infection, which remain prevalent in federal penitentiaries. Higher rates of testing are warranted for at-risk inmates to improve early detection of infection and provide infected inmates with timely care and treatment. For those who remain free of infection, testing can provide the additional benefits of exposing inmates to health counselling and for the reinforcement of prevention messages. The period of incarceration is also a critical opportunity to link inmates with outside resources in preparation for release to the community.

Integrating laboratory and epidemiological techniques for population-based surveillance of HIV strains and drug resistance in Canada.

&NA; This article describes the methods, results and future perspectives of four information sources used to monitor the HIV epidemic in Canada: AIDS case surveillance, HIV case surveillance, HIV sentinel serosurveillance, and behavioral surveillance. Synthesizing data from these multiple sources provides a more comprehensive picture of the HIV epidemic than any one source alone could provide. In Canada, there has been a shift over time from an epidemic dominated by men who have sex with men to one where more than half of new infections are attributed to other groups, such as injection drug users and non‐injecting heterosexuals. The available evidence also suggests increasing HIV infections among Aboriginal persons and among women. Surveillance data have been used in Canada to guide prevention and care programs and to formulate policy. In particular, these data have been used to support the development of an HIV testing program in pregnancy, to re‐direct community work toward injection drug users and the young, and to demonstrate the effectiveness of new treatments for HIV. The main challenge now is to continue to improve the monitoring of the shifting HIV epidemic with more accurate data and to use the resulting information to inform appropriate prevention and care responses.

RAR hath wrought…Hobson’s choice?

Gayatri C Jayaraman PhD MPH, Chris P Archibald MDCM FRCPC, Lee Lior MD MSc, Donald Sutherland MD MCommH MSc(Epi) HIV is among the most genetically variable of human pathogens. Two major factors contribute to this genetic diversity: the error-prone activity of reverse transcriptase, which is estimated to introduce an average of one error/genome/replication cycle (1), and recombination, which occurs at a rate of about 2%/kilobase/replication cycle (2). With the advent of international collaborations using powerful new tools that allow for the analyses of nucleotide sequence information, it became apparent that the initial classification of HIV into HIV-1 and HIV-2 based on geographic distribution was inadequate. We now recognize that HIV-1 can be divided into three major phylogenetic groups: ‘M’ (major), ‘O’ (outlier) and more recently, ‘N’ (new). The vast majority of isolates cluster in the M group. Based on sequencing the envelope gene, env, 10 phylogenetic subtypes (A to J) have been identified within this group, with subtypes A to E (also referred to as the circulating recombinant A/E) being the most common (3). The general pattern of subtype distribution by geographic location is shown in Table 1. The second major group of HIV-1, group O, is found mainly in Cameroon and Gabon, and differs from the M group by as many as 50% of residues (4). The N group of HIV-1 was isolated in Cameroon, with genetic characteristics of both the simian immunodeficiency virus and HIV-1 (M group) (5). Although there has been no systematic surveillance for genetic diversity of HIV strains in Canada, existing studies on high risk populations suggest that HIV-1 subtype B is the most common subtype found in this country. Bernier et al (6) have conducted analyses on HIV-1 sequence diversity among 17 infected injection drug users (IDUs) and among five men who have sex with men (MSM) residing in Montreal, and all sequences were of HIV-1 subtype B. As a part of an outbreak study in Newfoundland, Montpetit et al (7) analyzed serological samples from 31 HIV-positive persons of both sexes, comprising approximately 25% of known HIV-positive persons in the province, to determine the extent of HIV-1 subtype variation (7). All samples tested were of HIV-1 subtype B. Strain analysis has been carried out on samples from 13 MSM, two IDUs and two heterosexuals, recruited through POLARIS in Ontario (8). All have been found to be subtype B. The British Columbia Centre for Excellence in HIV/AIDS in Vancouver, British Columbia, has conducted genetic analysis of HIV linked to VIDUS (9). All 64 IDUs tested were infected with subtype B. Despite the predominance of HIV-1 subtype B, non-B subtypes have also been reported in Canada. As early as 1995, HIV-1 subtype A was identified in an African-born male, who moved to Canada in 1983 (10). Studies by the British Columbia Centre for Excellence in HIV/AIDS suggest that non-B subtypes represent at least 4% of HIV infections among

Darunavir: pharmacokinetics and drug interactions.

Rapid Assessment and Response (RAR) is proposed as a useful tool to undertake rapid assessments of injection drug use and its adverse effects on health, and to suggest an appropriate action plan (World Health Organization, 1998). Friedman has presented a cautionary argument, emphasising that RAR is as yet unproven and asking some pointed questions about its merit (Friedman, 1999). We have piloted an RAR approach in a developed country setting (Ottawa, Canada) where a significant problem of injection drug use exists, especially regarding HIV infection among injection drug users (IDUs) (Alary et al., 1999). Although this setting likely has more resources and more pre-existing data than do many developing country settings, we learned some valuable lessons that are general and therefore pertinent to the points made by Friedman. Friedman’s first point is a most important one: does RAR lead to outcomes that improve public health? To answer this question, proper evaluation is indeed needed, but such evaluation is not easy for community-level interventions. Certainly, Friedman is correct in saying that this question has not yet been answered and more research is needed. However, more research is also needed on how best to use the type of information produced by RAR. In general, information derived from qualitative and from ethnographic studies is not used as much as it should be to inform health programmes and policies at the local, regional, and national levels. The rapid assessment methodology is able to generate relevant qualitative and quantitative information pertaining to health care and disease control, and we need to understand better how to best use these diverse types of information for improved prevention and care. Is RAR ‘‘second-rate science’’? Of course it is, or else it would not be rapid; after all, even a cake cannot be both possessed and eaten. First-rate science proceeds at a slow, * Corresponding author. Present address: Division of HIV Epidemiology, Brooke Claxton Building, Room 0108B, Tunney’s Pasture 0900B1, Ottawa, Canada K1A OL2. Fax: +1613-954-5414. E-mail address: chris–archibald@hc-sc.gc.ca (C.P. Archibald)