Surita Parashar

Women and Vulnerability to HAART Non-Adherence: A Literature Review of Treatment Adherence by Gender from 2000 to 2011

A literature review of original research articles on adherence to antiretroviral therapy (ART) in developed countries, covering January 2000 to June 2011, was conducted to determine if gender differences exist in the prevalence of nonadherence to ART. Of the 1,255 articles reviewed, only 189 included data on the proportion of the study population that was adherent and only 57 (30.2%) of these reported proportional adherence values by gender. While comparing articles was challenging because of varied reporting strategies, women generally exhibit poorer adherence than men. Thirty of the 44 articles (68.2%) that reported comparative data on adherence by gender found women to be less adherent than men. Ten articles (17.5%) reported significant differences in proportional adherence by gender, nine of which showed women to be less adherent than men. These findings suggest that in multiple studies from developed countries, female gender often predicts lower adherence. The unique circumstances of HIV–positive women require specialized care to increase adherence to ART.

Employment predicts decreased mortality among HIV-seropositive illicit drug users in a setting of universal HIV care

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.

Harder-to-reach people living with HIV experiencing high prevalence of all-type mental health disorder diagnosis

ABSTRACT People living with HIV/AIDS (PHA) often concurrently cope with mental health disorders that may greatly influence HIV and other health-related outcomes. The objective of this study was to examine the prevalence and correlates of self-reported mental health disorder diagnosis among a cohort of harder-to-reach HIV-positive individuals in British Columbia, Canada. Between 2007 and 2010, 1000 PHA who had initiated ART were enrolled in the Longitudinal Investigation into Supportive and Ancillary health services (LISA) study. Socio-demographic, behavioral, health-care utilization and psychosocial information was collected through interviewer-led questionnaires and linked to longitudinal clinical variables through the provincial Drug Treatment Program at the BC Centre for Excellence in HIV/AIDS. We identified the prevalence of all-type and specific mental health disorders among this population. Of the 916 participants included in this analysis, 494 (54%) reported ever having a mental health disorder diagnosis. Mood (85%) and anxiety (65%) disorders were the two most frequently reported mental health conditions. Self-reported all-type mental health disorder was independently associated with decreased overall functioning (adjusted odds ratio [AOR] = 0.90, 95% confidence interval [CI] = 0.83–0.98) and life satisfaction (AOR = 0.81, 95% CI = 0.74–0.89), and having higher stigma score (AOR = 1.11, 95%CI = 1.02–1.21). Participants reporting any mental health disorder were more likely to report a history of sexual assault (AOR = 2.45, 95% CI = 1.75–3.43) and to have used case management services (AOR = 1.63, 95%CI = 1.17–2.27). Our findings uncovered a high burden of mental health disorders among harder-to-reach PHA and suggest that PHA with at least one mental health disorder diagnosis are disproportionately impacted by sexual violence and stigma.

The population impact of eliminating homelessness on HIV viral suppression among people who use drugs.

Objective:We sought to estimate the change in viral suppression prevalence if homelessness were eliminated from a population of HIV-infected people who use drugs. Design:Community-recruited prospective cohort of HIV-infected people who use drugs in Vancouver, Canada. Behavioural information was collected at baseline and linked to a province-wide HIV/AIDS treatment database. The primary outcome was viral suppression (<50 copies/ml) measured during subsequent routine clinical care. Methods:We employed an imputation-based marginal modelling approach. First, we used modified Poisson regression to estimate the relationship between homelessness and viral suppression (adjusting for sociodemographics, substance use, addiction treatment, and other confounders). Then, we imputed an outcome probability for each individual while manipulating the exposure (homelessness). Population viral suppression prevalence under realized and ‘housed’ scenarios were obtained by averaging these probabilities across the study population. Bootstrapping was conducted to calculate 95% confidence limits. Results:Of 706 individuals interviewed between January 2005 and December 2013, the majority were men (66.0%), of white race/ethnicity (55.1%), and had a history of injection drug use (93.6%). At first study visit, 223 (31.6%) reported recent homelessness, and 37.8% were subsequently identified as virally suppressed. Adjusted marginal models estimated a 15.1% relative increase [95% confidence interval (CI) 9.0–21.7%) in viral suppression in the entire population – to 43.5% (95% CI 39.4–48.2%) – if all homeless individuals were housed. Among those homeless, eliminating this exposure would increase viral suppression from 22.0 to 40.1% (95% CI 35.1–46.1%), an 82.3% relative increase. Conclusion:Interventions to house homeless, HIV-positive individuals who use drugs could significantly increase population viral suppression. Such interventions should be implemented as a part of renewed HIV/AIDS prevention and treatment efforts.

The impact of unstable housing on emergency department use in a cohort of HIV-positive people in a Canadian setting

The social–structural challenges experienced by people living with HIV (PHA) have been shown to contribute to increased use of the emergency department (ED). This study identified factors associated with frequent and nonurgent ED use within a cohort of people accessing antiretroviral therapy (ART) in a Canadian setting. Interviewer-administered surveys collected socio-demographic information; clinical variables were obtained through linkages with the provincial drug treatment registry; and ED admission data were abstracted from the Department of Emergency Medicine database. Multivariate logistic regression was used to compute odds of frequent and nonurgent ED use. Unstable housing was independently associated with ED use (adjusted odds ratio [AOR] =1.94, 95% confidence interval [CI] 1.24–3.04]), having three or more ED visits within 6 months of the interview date [AOR: 2.03 (95% CI: 1.07–3.83)] and being triaged as nonurgent (AOR = 2.71, 95% CI: 1.19–6.17). Frequent and nonurgent use of the ED in this setting is associated with conditions requiring interventions at the social–structural level. Supportive housing may contribute to decreased health-care costs and improved health outcomes amongst marginalized PHA.

Reducing rates of preventable HIV/AIDS-associated mortality among people living with HIV who inject drugs.

Purpose of reviewThe modern antiretroviral therapy (ART) era has seen substantial reductions in mortality among people living with HIV. However, HIV-positive people who inject drugs (PWIDs) continue to experience high rates of suboptimal HIV-related outcomes. We review recent findings regarding factors contributing to premature and preventable mortality among HIV-positive PWID, and describe the promise of interventions to improve survival in this group. Recent findingsThe current leading causes of death among HIV-positive PWID are HIV/AIDS-related causes, overdose, and liver-related causes, including infection with hepatitis C virus. Elevated mortality levels in this population are driven by social–structural barriers to ART access and adherence, particularly criminalization and stigmatization of drug use. In contexts where opioid substitution therapy and ART adherence support programs are widely accessible, evidence highlights comparable levels of survival among HIV-positive PWID and people living with HIV who do not inject drugs. SummaryThe life-saving benefits of ART can be realized among HIV-positive PWID when it is paired with strategies that address barriers to evidence-based medical care. Joint administration of ART and opioid substitution therapy, as well as repeal of punitive laws that criminalize drug users, are urgently needed to reduce HIV and injection-related mortality among PWID.

Factors associated with initiation of antiretroviral therapy among HIV-positive people who use injection drugs in a Canadian setting.

Objective:To identify behavioral, social, and structural factors associated with time from HIV seroconversion to antiretroviral therapy (ART) initiation among people who use injection drugs (PWID). Design:Two complementary prospective cohorts of PWID linked to comprehensive ART dispensation records in a setting of universal no-cost HIV/AIDS treatment and care. Methods:Multivariable extended Cox models of time to ART initiation among baseline HIV-seronegative PWID who seroconverted after recruitment adjusted with a time-updated measure of clinical eligibility for ART. Results:We included 133 individuals of whom 98 (74%) initiated ART during follow-up at a rate of 12.4 per 100 person-years. In a multivariable model adjusted for ART eligibility, methadone maintenance therapy [adjusted hazard ratio (AHR) = 2.37, 95% confidence interval (95% CI): 1.56–3.60] and a more recent calendar year of observation (AHR = 1.06, 95% CI: 1.00–1.12) were associated with more rapid ART initiation, whereas informal income generation (AHR = 0.51, 95% CI: 0.32–0.79) and incarceration (AHR = 0.52, 95% CI: 0.28–0.97) were negatively associated with ART initiation. Conclusion:In this sample of community-recruited HIV-positive PWID with well defined dates of HIV seroconversion, we found that two measures related to the criminalization of illicit drug use each independently delayed ART initiation regardless of clinical eligibility. Engagement in methadone promoted ART initiation. Programs to scale-up HIV treatment among PWID should consider decreased criminalization of PWID and increased access to opioid substitution therapy to optimize the impact of ART on HIV/AIDS-associated morbidity, mortality, and HIV transmission.

Meaningful engagement of people living with HIV who use drugs: methodology for the design of a Peer Research Associate (PRA) hiring model

BackgroundCommunity-based HIV, harm reduction, and addiction research increasingly involve members of affected communities as Peer Research Associates (PRAs)—individuals with common experiences to the participant population (e.g. people who use drugs, people living with HIV [PLHIV]). However, there is a paucity of literature detailing the operationalization of PRA hiring and thus limited understanding regarding how affected communities can be meaningfully involved through low-barrier engagement in paid positions within community-based participatory research (CBPR) projects. We aim to address this gap by describing a low-threshold PRA hiring process.ResultsIn 2012, the BC Centre for Excellence in HIV/AIDS and the Dr. Peter AIDS Foundation collaborated to develop a mixed-method CBPR project evaluating the effectiveness of the Dr. Peter Centre (DPC)—an integrative HIV care facility in Vancouver, Canada. A primary objective of the study was to assess the impact of DPC services among clients who have a history of illicit drug use. In keeping with CBPR principles, affected populations, community-based organizations, and key stakeholders guided the development and dissemination of a low-barrier PRA hiring process to meaningfully engage affected communities (e.g. PLHIV who have a history of illicit drug use) in all aspects of the research project.The hiring model was implemented in a number of stages, including (1) the establishment of a hiring team; (2) the development and dissemination of the job posting; (3) interviewing applicants; and (4) the selection of participants. The hiring model presented in this paper demonstrates the benefits of hiring vulnerable PLHIV who use drugs as PRAs in community-based research.ConclusionsThe provision of low-barrier access to meaningful research employment described herein attempts to engage affected communities beyond tokenistic involvement in research. Our hiring model was successful at engaging five PRAs over a 2-year period and fostered opportunities for future paid employment or volunteer opportunities through ongoing collaboration between PRAs and a diverse range of stakeholders working in HIV/AIDS and addictions. Additionally, this model has the potential to be used across a range of studies and community-based settings interested in meaningfully engaging communities in all stages of the research process.

The effect of engagement in an HIV/AIDS integrated health programme on plasma HIV-1 RNA suppression among HIV-positive people who use illicit drugs: a marginal structural modelling analysis

HIV treatment‐as‐prevention campaigns emphasize early diagnosis and immediate access to care and antiretroviral therapy for HIV‐positive individuals in order to increase levels of plasma HIV RNA viral load (VL) suppression. However, the possible role of harm reduction‐based programmes in this objective has not yet been well evaluated. The objective of the study was to examine the relationship between being a client of the Dr. Peter Centre (DPC; an HIV/AIDS‐focused adult integrated health programme) and VL suppression among highly active antiretroviral therapy (HAART)‐exposed HIV‐positive people who use illicit drugs (PWUD) in Vancouver, Canada.

The Place of Housing Stability in HIV Research: A Critical Review of the Literature

Abstract There exists a wealth of literature investigating the association between housing stability and the health of people living with, or at risk of acquiring, HIV. Following a review of the limitations of prevailing housing status measures, the concepts underlying definitions of housing status in HIV literature are presented. This review concludes by proposing a conceptual shift away from understanding housing as a predominantly material entity towards a more holistic understanding of the social and cultural importance people place on home, and various spaces people find and make “home”. Addressing the varied housing needs of people living with, and at risk of, HIV relies on a more careful consideration of context, and a commitment to cultivating and supporting spaces which allow people to manage their health and well-being.