Search

Background: The benefits of highly active antiretroviral therapy (HAART) for the treatment of HIV infection are well documented, but concerns regarding access and adherence to HAART are growing. We evaluated virological responses to HAART among HIV-1 infected patients who were injection drug users (IDUs) in a population-based setting where HIV/AIDS care is delivered free of charge. Methods: We evaluated previously untreated HIV-1 infected men and women who initiated HAART between Aug. 1, 1996, and July 31, 2000, and who were followed until Mar. 31, 2002, in a province-wide HIV treatment program. We used Kaplan--Meier methods and Cox proportional hazards regression in our evaluation of time to suppression (i.e., less than 500 copies/mL) and rebound (i.e., 500 copies/mL or more) of plasma HIV-1 RNA, with patients stratified according to whether or not they had a history of injection drug use. Results: Overall, 1422 patients initiated HAART during the study period, of whom 359 (25.2%) were IDUs. In Kaplan--Meier analyses, the cumulative suppression rate at 12 months after initiation of HAART was 70.8% for non-IDUs... [ABSTRACT FROM AUTHOR]

Background: More than 93% of the nearly $500 million spent annually on Canada's drug strategy goes toward efforts to reduce the illicit drug supply. However, little is known about the effectiveness of this strategy. On Sept. 2, 2000, Canadian police seized approximately 100 kg of heroin in one of the nation's largest-ever seizures of this drug. An ongoing prospective cohort study of injection drug users afforded an opportunity to evaluate the impact of this seizure.Methods: The Vancouver Injection Drug User Study is a prospective cohort study of injection drug users that began in 1996. The present study relied primarily on data acquired from participants who were seen during the 30-day periods immediately before and after the seizure. We compared drug use and behavioural characteristics, heroin and cocaine prices, and participants' reports of whether law enforcement had affected their source of drugs or the types of drugs available on the street, as well as overdoses, in these 2 periods.Results: The 138 participants seen before the seizure were similar to the 123 participants seen after the seizure with respect to age, sex, ethnic background, education, HIV serostatus, neighbourhood residence, instability of housing, employment status, use of methadone maintenance therapy and all other measured potential confounders (all p > 0.10). We found no difference in the extent to which participants in the 2 groups reported daily use of heroin, frequency of nonfatal overdoses, or whether law enforcement had affected their source of drugs or the types of drugs available on the street (all p > 0.10). Although we detected no difference in the price of cocaine, the median reported price of heroin went down after the seizure (p = 0.034), which suggests that other shipments compensated for the seizure. External evaluations of deaths from overdoses and heroin purity indicated that the seizure had no impact, nor was any impact seen when the periods of analysis were extended.Interpretation: The massive heroin seizure appeared to have no measurable public health benefit. Closer scrutiny of enforcement efforts is warranted to ensure that resources are delivered to the most efficient and cost-effective public health programs. [ABSTRACT FROM AUTHOR]

Background: Because of established links between entrenched poverty and risk of HIV infection, there have long been warnings that HIV/AIDS will disproportionately affect Aboriginal people in Canada. We compared HIV incidence rates among Aboriginal and non-Aboriginal injection drug users (IDUs) in Vancouver and studied factors associated with HIV seroconversion among Aboriginal participants.Methods: This analysis was based on 941 participants (230 Aboriginal people) recruited between May 1996 and December 2000 who were seronegative at enrollment and had completed at least one follow-up visit. Incidence rates were calculated using the Kaplan-Meier method. The Cox proportional hazards regression model was used to identify independent predictors of time to HIV seroconversion among female and male Aboriginal IDUs.Results: As of May 31, 2001, seroconversion had occurred in 112 (11.9%) of the participants, yielding a cumulative incidence of HIV infection at 42 months of 12.7% (95% confidence interval [CI] 10.3%-15.1%). The cumulative incidence at 42 months was significantly higher among the Aboriginal participants than among the non-Aboriginal participants (21.1% v. 10.7%, p < 0.001). This elevation in risk was present in both female and male Aboriginal IDUs. Among the female Aboriginal IDUs, frequent speedball (combined cocaine and heroin) injection (adjusted relative risk [RR] 3.1; 95% CI 1.4-7.1) and going on binges of injection drug use (adjusted RR 2.3; 95% CI 1.0-5.2) were found to be independent predictors of HIV seroconversion. Among the male Aboriginal IDUs, the independent predictors of seroconversion were frequent speedball injection (adjusted RR 2.9; 95% CI 1.0-8.5) and frequent cocaine injection (adjusted RR 2.5; 95% CI 1.0-6.5).Interpretation: In Vancouver, Aboriginal IDUs are becoming HIV positive at twice the rate of non-Aboriginal IDUs. Our findings emphasize the urgent need for an appropriate and effective public health strategy--planned and implemented in partnership with Aboriginal AIDS service organizations and the Aboriginal community--to reduce the harms of injection drug use in this population. [ABSTRACT FROM AUTHOR]

Background: Hospital discharge against medical advice, especially among substance-abusing populations, is a frustrating problem for health care pro-viders. Because of the high prevalence of injection drug use among HIV- positive patients admitted to hospital in Vancouver, we explored the factors associated with leaving hospital against medical advice in this population. Methods: We reviewed records for all HIV/AIDS patients admitted to St. Paul's Hospital, Vancouver, between Apr. 1, 1997, and Mar. 1, 1999. After identifying the first ("index") admission during this period, we followed the patients' records for 1 year. Multivariate models were applied to identify the determinants of discharge against medical advice and to estimate the impact of such discharge on readmission rate, readmission frequency and length of stay in hospital. Results Of 981 index admissions among HIV/AIDS patients, 125 (13%) of the patients left the hospital against medical advice. Departure on the day on which welfare cheques were issued and a history of injection drug use were significant predictors of leaving against medical advice. After adjusting for sex, age, severity of illness, injection drug use and homelessness, we found that patients leaving against medical advice were readmitted more frequently than those who were formally discharged (frequency ratio 1.25, 95% confidence interval [CI] 1.11-1.42), were more likely to be readmitted with a related diagnosis within 30 days (odds ratio 5.00, 95% CI 3.04-8.24) and had significantly longer lengths of stay in the follow-up period. Interpretation Discharge against medical advice among HIV-positive patients was associated with frequent readmissions with the same diagnosis. Preventing such discharges is likely to benefit patients (by improving their health status) and the health care system (by reducing unnecessary readmissions). [ABSTRACT FROM AUTHOR]

Abstract Background: In 1997, we found a higher prevalence of HIV among female than among male injection drug users in Vancouver. Factors associated with HIV incidence among women in this setting were unknown. In the present study, we sought to compare HIV incidence rates among male and female injection drug users in Vancouver and to compare factors associated with HIV seroconversion. Methods: This analysis was based on 939 participants recruited between May 1996 and December 2000 who were seronegative at enrolment with at least one follow-up visit completed, and who were studied prospectively until March 2001. Incidence rates were calculated using the Kaplan-Meier method. The Cox proportional hazards regression model was used to identify independent predictors of time to HIV seroconversion. Results: As of March 2001, seroconversion had occurred in 110 of 939 participants (64 men, 46 women), yielding a cumulative incidence rate of HIV at 48 months of 13.4% (95% confidence interval [CI] 11.0%-15.8%). Incidence was higher among women than among men (16.6% v. 11.7%, p = 0.074). Multivariate analysis of the female participants' practices revealed injecting cocaine once or more per day compared with injecting less than once per day (adjusted relative risk [RR] 2.6, 95% CI 1.4-4.8), requiring help injecting compared with not requiring such assistance (adjusted RR 2.1, 95% CI 1.1-3.8), having unsafe sex with a regular partner compared with not having unsafe sex with a regular partner (adjusted RR 2.9, 95% CI 0.9-9.5) and having an HIV-positive sex partner compared with not having an HIV-positive sex partner (adjusted RR 2.7, 95% CI 1.0-7.7) to be independent predictors of time to HIV seroconversion. Among male participants, injecting cocaine once or more per day compared with injecting less than once per day (adjusted RR 3.3, 95% CI 1.9-5.6), self-reporting identification as an Aboriginal compared with not self-reporting identification as an Aboriginal (adjusted RR 2... [ABSTRACT FROM AUTHOR]

Presents reader letters on medical issues as of February 19, 2002. Publication of recommendations for baseline staging tests in breast cancer by the Breast Cancer Disease Site Group of the Cancer Care Ontario Practice Guidelines Initiative; Economic aspects of safe injection facilities for drug users; Others.

Because of high transmissibility of HCV among those injecting frequently and using cocaine, the harm reduction initiatives deployed in Vancouver during the study period proved insufficient to eliminate hepatitis C transmission in this population. [ABSTRACT FROM AUTHOR]

Background: Many injection drug users (IDUs) seek care at emergency departments and some require hospital admission because of late presentation in the course of their illness. We determined the predictors of frequent emergency department visits and hospital admissions among community-based IDUs and estimated the incremental hospital utilization costs incurred by IDUs with early HIV infection relative to costs incurred by HIV-negative IDUs.Methods: The Vancouver Injection Drug User Study (VIDUS) is a prospective cohort study involving IDUs that began in 1996. Our analyses were restricted to the 598 participants who gave informed consent for our study. We used the participants' responses to the baseline VIDUS questionnaire and, from medical records at St. Paul's Hospital, Vancouver, we collected detailed information about the frequency of emergency department visits, hospital admissions and the primary diagnosis for all visits or hospital stays between May 1, 1996, and Aug. 31, 1999. The incremental difference in hospital utilization costs by HIV status was estimated, based on 105 admissions in a subgroup of 64 participants.Results: A total of 440 (73.6%) of the 598 IDUs made 2763 visits to the emergency department at St. Paul's Hospital during the study period. Of these 440, 265 (160.2%) made frequent visits (3 or more). The following factors were associated with frequent use: HIV-positive status (seroprevalent: adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2-2.6; seroconverted during study period: adjusted OR 3.0, 95% CI 1.6-5.7); more than 4 injections daily (adjusted OR 1.5, 95% CI 1.1-2.1); cocaine use more frequent than use of other drugs (adjusted OR 2.0, 95% CI 1.2-3.6); and unstable housing (adjusted OR 1.5, 95% CI 1.1-2.2). During the study period 210 of the participants were admitted to hospital 495 times; 118 (56.2%) of them were admitted frequently (2 or more admissions). The 2 most common reasons for admission were pneumonia (132 admissions among 79 patients) and soft-tissue infections (cellulitis and skin abscess) (90 admissions among 59 patients). The following factors were independently associated with frequent hospital admissions: HIV-positive status (seroprevalent: adjusted OR 5.4, 95% CI 3.4-8.6; seroconverted during study period: adjusted OR 2.9, 95% CI 1.4-6.0); and female sex (adjusted OR 1.8, 95% CI 1.1-3.1). The incremental hospital utilization costs incurred by HIV-positive IDUs relative to the costs incurred by HIV-negative IDUs were $1752 per year.Interpretation: Hospital utilization was significantly higher among community-based IDUs with early HIV disease than among those who were HIV negative. Much of the hospital use was related to complications of injection drug use and may be reduced with the establishment of programs that integrate harm reduction strategies with primary care and addiction treatment. [ABSTRACT FROM AUTHOR]

Background: In several European countries safer injecting rooms have reduced the public disorder and health-related problems of injection drug use. We explored factors associated with needle-sharing practices that could potentially be alleviated by the availability of safer injecting rooms in Canada.Methods: The Vancouver Injection Drug User Study is a prospective cohort study of injection drug users (IDUs) that began in 1996. The analyses reported here were restricted to the 776 participants who reported actively injecting drugs in the 6 months before the most recent follow-up visit, during the period January 1999 to October 2000. Needle sharing was defined as either borrowing or lending a used needle in the 6-month period before the interview.Results: Overall, 214 (27.6%) of the participants reported sharing needles during the 6 months before follow-up; 106 (13.7%) injected drugs in public, and 581 (74.9%) reported injecting alone at least once. Variables independently associated with needle sharing in a multivariate analysis included difficulty getting sterile needles (adjusted odds ratio [OR] 2.7, 95% confidence interval [CI] 1.8-4.1), requiring help to inject drugs (adjusted OR 2.0, 95% CI 1.4-2.8), needle reuse (adjusted OR 1.8, 95% CI 1.3-2.6), frequent cocaine injection (adjusted OR 1.6, 95% CI 1.1-2.3) and frequent heroin injection (adjusted OR 1.5, 95% CI 1.04-2.1). Conversely, HIV-positive participants were less likely to share needles (adjusted OR 0.5, 95% CI 0.4-0.8), although 20.2% of the HIV-positive IDUs still reported sharing needles.Interpretation: Despite the availability of a large needle-exchange program and targeted law enforcement efforts in Vancouver, needle sharing remains an alarmingly common practice in our cohort. We identified a number of risk behaviours--difficulty getting sterile needles, needle sharing and reuse, injection of drugs in public and injecting alone (one of the main contributing causes of overdose)--that may be alleviated by the establishment of supervised safer injecting rooms. [ABSTRACT FROM AUTHOR]

Offers a study that evaluates the demographic and clinical determinants of admission to hospital among HIV-positive patients receiving antiretroviral therapy in British Columbia. Methods; Results; Interpretation.

AbstractBackground: Young gay and bisexual men may perceive that the consequences of HIV infection have dramatically improved with the availability of highly active antiretroviral therapy. We therefore sought to identify trends in HIV infection rates and associated risk behaviours among young gay and bisexual men in Vancouver.Methods: Prospective cohort study involving gay and bisexual men aged 18-30 years who had not previously tested HIV positive. Subjects were recruited through physicians, clinics and community outreach in Vancouver. Annually participants were tested for HIV antibodies and asked to complete a self-administered questionnaire pertaining to sociodemographic characteristics, sexual behaviours and substance use. Prevalence of HIV infection and risk behaviours were determined for eligible participants who completed a baseline questionnaire and HIV testing as of May 1998. The primary outcome was the proportion of men who reported having protected sex during the year before enrolment and who reported any episode of unprotected sex by the time of the first follow-up visit.Results: A total of 681 men completed a baseline questionnaire and HIV testing as of May 1998. The median duration between baseline and the first follow-up visit was 14 months. The median age was 25 years. Most of the subjects were white and of high socioeconomic status. The majority (549 [80.6%]) reported having sex only with men; 81 (11.9%) reported bisexual activity. Of the 503 men who had one or more regular male partners, 245 (48.7%) reported at least one episode of unprotected anal sex in the year before enrolment; the corresponding number among the 537 who had one or more casual male partners was 140 (26.1%). The prevalence and incidence of HIV seropositivity were 1.8% (95% confidence interval [CI] 0.8%-2.8%) and 1.7 per 100 person-years [95% CI 0.7-2.7], respectively. Fifty-two (26.5%) of the 196 and 55 (29.7%) of the 185 men with regular partners who reported having practised... [ABSTRACT FROM AUTHOR]

Compares mortality and AIDS-free survival among HIV-infected patients in British Columbia who were treated with double- and triple-drug regimes. Methods; Results; Interpretation that treatment with a triple-drug antiretroviral regimen comprising 2 nucleoside analogue reverse transcriptase inhibitors (NRTI) plus a protease inhibitor or a non-NRTI have a lower risk of morbidity and death.

Editorial. Comments on the lack of HIV prevention programs for injection drug users in Canada. Problems in the implementation of needle exchange programs; Benefits of needle exchange program; Medical costs of treating HIV-infected drug users.

Editorial. Discusses implications of the study by Dr. Robert S. Remis et al in the August 15, 1997 edition of the Canadian Medical Association Journal which found low risk in acquiring HIV in Canada in the 1990s through a blood transfusion. News that should allay public fears but will not; Risk perceived to be high although it is low; People's underestimation of sexual and parental transmission of HIV; Details of Remis study; Safety issues; Role of physician in matter.