Thomas Kerr

Determinants of HAART discontinuation among injection drug users

Abstract The objective of this study was to identify psychosocial determinants of, and self-reported reasons for, HAART discontinuation among HIV-positive injection drug users (IDUs). We examined correlates between sociodemographic characteristics, drug use and risk behaviors, outcome expectations, adherence self-efficacy, social support and HAART discontinuation among 160 HIV-positive participants in the Vancouver Injection Drug Users’ Study (VIDUS). Logistic regression was used to identify the factors independently associated with discontinuation of HAART. Seventy-one (44%) study participants discontinued HAART during the study period. Factors independently associated with discontinuation of HAART included recent incarceration (ORu200a=u200a4.84, p=0.022), negative outcome expectations (ORu200a=u200a1.41, p=0.001), adherence efficacy expectations (ORu200a=u200a0.70, p=0.003) and self-regulatory efficacy (ORu200a=u200a0.86, p=0.050). The most frequently cited reasons provided for discontinuing HAART were being in jail (44%) and medication side effects (41%). The results of this study suggest that psychological constructs derived from self-efficacy theory are highly germane to the understanding of HAART discontinuation behavior and interventions that may change it. Incarceration may result in interruptions in HAART among IDUs, and programmatic changes may be needed to promote optimal retention on HAART among incarcerated HIV-infected IDUs.

Responding to an Explosive HIV Epidemic Driven by Frequent Cocaine Injection: Is There a Role for Safe Injecting Facilities?

Although there have been repeated calls for the establishment of safe injection facilities (SIFs) in Vancouver since the early 1990s, questions remain concerning the feasibility of SIFs due to the high prevalence of injection cocaine and the concomitant problems cocaine use presents. Therefore, we determined the prevalence of willingness to attend SIFs among cocaine injectors in Vancouver and explored the factors associated with this willingness, using data from the Vancouver Injection Drug Users Study. After considering the results derived from this analysis, additional qualitative methods were employed to explore further willingness to use SIFs, barriers and facilitators of SIF utilization, and methods of maximizing use among selected subpopulations of cocaine injectors. The results suggest that a high proportion of cocaine injectors, including some of those most at risk, would attend an SIF if one were available. However, in order to better accommodate cocaine injectors, several modifications could be made to conventional SIF service design and delivery. The vast majority of these modifications relate to ensuring effective responses to cocaine toxicity. Given the acceptability of SIFs among cocaine injectors, it appears that an SIF pilot could result in significant and immediate benefits in terms of public health and community safety.

Harm reduction in prisons: a 'rights based analysis'

Throughout most of the world, the primary response to problems associated with illicit injection drug use has been to intensify law enforcement efforts. This strategy has contributed to an unprecedented growth in prison populations and growing concerns regarding drug-related harm within prisons. Despite the presence of international laws and guidelines that call for the protection of the health of prisoners, prison authorities have generally been slow to implement activities that have been proven effective in reducing drug-related harms in community settings. While a limited number of countries have made progress by implementing educational programmes, methadone maintenance therapy, bleach distribution and needle exchange, in most areas of the world, a substantially greater effort is needed to ensure that prisoners receive the same level of care offered in community settings. The current emphasis on security and abstinence from drugs within prisons is often regarded as incongruent with the goals and methods of harm reduction. However, available evidence indicates that most harm-reduction programmes can be implemented within prisons without compromising security or increasing illicit drug use.

Prevalence and predictors of facing a legal obligation to disclose HIV serostatus to sexual partners among people living with HIV who inject drugs in a Canadian setting:a cross-sectional analysis

BACKGROUNDnIn October 2012, the Canadian Supreme Court ruled that people living with HIV must disclose their HIV status before sex that poses a realistic possibility of HIV transmission, clarifying that in circumstances where condom-protected penile-vaginal intercourse occurred with a low viral load (< 1500 copies/mL), the realistic possibility of transmission would be negated. We estimated the proportion of people living with HIV who use injection drugs who would face a legal obligation to disclose under these circumstances.nnnMETHODSn: We used cross-sectional survey data from a cohort of people living with HIV who inject drugs. Participants interviewed since October 2012 who self-reported recent penile-vaginal intercourse were included. Participants self-reporting 100% condom use with a viral load consistently < 1500 copies/mL were assumed to have no legal obligation to disclose. Logistic regression identified factors associated with facing a legal obligation to disclose.nnnRESULTSnWe included 176 participants, 44% of whom were women: 94% had a low viral load, and 60% self-reported 100% condom use. If condom use and low viral load were required to negate the realistic possibility of transmission, 44% would face a legal obligation to disclose. Factors associated with facing a legal obligation to disclose were female sex (adjusted odds ratio [OR] 2.19, 95% confidence interval [CI] 1.13-4.24), having 1 recent sexual partner (v. > 1) (adjusted OR 2.68, 95% CI 1.24-5.78) and self-reporting a stable relationship (adjusted OR 2.00, 95% CI 1.03-3.91).nnnINTERPRETATIONnAlmost half the participants in our analytic sample would face a legal obligation to disclose to sexual partners under these circumstances (with an increased burden among women), adding further risk of criminalization within this marginalized and vulnerable community.