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Background Avoiding “causal” language with observational study designs is common publication practice, often justified as being a more cautious approach to interpretation. Objectives We aimed to i) estimate the degree to which causality was implied by both the language linking exposures to outcomes and by action recommendations in the high-profile health literature, ii) examine disconnects between language and recommendations, iii) identify which linking phrases were most common, and iv) generate estimates by which these phrases imply causality. Methods We identified 18 of the most prominent general medical/public health/epidemiology journals, and searched and screened for articles published from 2010 to 2019 that investigated exposure/outcome pairs until we reached 65 non-RCT articles per journal (n=1,170). Two independent reviewers and an arbitrating reviewer rated the degree to which they believed causality had been implied by the language in abstracts based on written guidance. Reviewers then rated causal implications of linking words in isolation. For comparison, additional review was performed for full texts and for a secondary sample of RCTs. Results Reviewers rated the causal implication of the sentence and phrase linking the exposure and outcome as None (i.e., makes no causal implication) in 13.8%, Weak in 34.2%, Moderate in 33.2%, and Strong in 18.7% of abstracts. Reviewers identified an action recommendation in 34.2% of abstracts. Of these action recommendations, reviewers rated the causal implications as None in 5.3%, Weak in 19.0%, Moderate in 42.8% and Strong in 33.0% of cases. The implied causality of action recommendations was often higher than the implied causality of linking sentences (44.5%) or commensurate (40.3%), with 15.3% being weaker. The most common linking word root identified in abstracts was “associate” (n=535/1,170; 45.7%) (e.g. “association,” “associated,” etc). There were only 16 (1.4%) abstracts using “cause” in the linking or modifying phrases. Reviewer ratings for causal implications of word roots were highly heterogeneous, including those commonly considered non-causal. Discussion We found substantial disconnects between causal implications used to link an exposure to an outcome and the action implications made. This undercuts common assumptions about what words are often considered non-causal and that policing them eliminates causal implications. We recommend that instead of policing words, editors, researchers, and communicators should increase efforts at making research questions, as well as the potential of studies to answer them, more transparent. Summary box

Social isolation, a risk factor for poor health within the general population, may be exacerbated by unique challenges faced by people living with HIV (PLHIV). This analysis examines the association between social isolation and all-cause mortality among a cohort of PLHIV experiencing multiple social vulnerabilities. The analytical sample included 936 PLHIV ≥ 19 years, living in British Columbia, Canada, and enrolled in the Longitudinal Investigation into Supportive and Ancillary Health Services (LISA) Study (2007–2010). Participants were classified as Socially Connected (SC), Minimally Isolated (MI) or Socially Isolated (SI) via latent class analysis. Cross-sectional survey data was linked to longitudinal clinical data from a provincial HIV treatment database. Mortality was assessed longitudinally up to and including December 31st, 2017. Through multivariable logistic regression, an association between SI and all-cause mortality was found (adjusted OR: 1.48; 95% CI 1.08, 2.01). These findings emphasize the need to mitigate effects of social isolation among PLHIV. Electronic supplementary material The online version of this article (10.1007/s10461-020-03000-2) contains supplementary material, which is available to authorized users.

BackgroundDue to stigma and discrimination, gay, bisexual and other men who have sex with men (gbMSM) potentially carry a heightened burden of loneliness. This analysis investigates loneliness among gbMSM and its relationship with self-rated physical health, along with the mediating effect of depression.MethodsParticipants were recruited using respondent-driven sampling into the Momentum Health Study (February 2012–February 2015) with follow-up visits occurring every 6 months until February 2018. Using computer-assisted self-interviews, measures of loneliness were assessed using a 6-item Loneliness Scale for Emotional and Social Loneliness (lonely vs not lonely). Current physical health was self-assessed (poor, fair, good, very good or excellent). A multivariable generalised linear-mixed model with a logit link function was used to examine the relationship between loneliness and self-rated physical health. We further investigated the mediating effect of depressive symptomatology on this relationship via the Hospital Anxiety and Depression Scale.ResultsOf the 770 participants included, we found that 61% (n=471) experienced loneliness at baseline. Of the 674 (88%) who reported good/very good/excellent physical health, 59% (n=391) reported loneliness, compared with 87% (n=80) of those in poor/fair self-rated physical health. After adjustment for confounding, loneliness was associated with poor self-rated physical health (adjusted OR 1.71; 95% CI 1.13 to 2.60). Depressive symptomatology was found to partially mediate this relationship.ConclusionThere may be a need for the integration of social, mental and physical health programming, targeted towards gbMSM, to alleviate the degree of loneliness experienced and its co-occurrence with poor self-rated physical health.

Longer survival has increased the likelihood of antiretroviral-treated people living with HIV (PLWH) developing age-associated comorbidities. We compared the burden of multimorbidity and all-cause mortality across HIV status in British Columbia (BC), and assessed the longitudinal effect of multimorbidity on all-cause mortality among PLWH.Antiretroviral-treated PLWH aged ≥19 years and 1:4 age-sex-matched HIV-negative individuals from a population-based cohort were followed for ≥1 year during 2001-2012. Diagnoses of seven age-associated comorbidities were identified from provincial administrative databases and grouped into 0, 1, 2, and ≥3 comorbidities. Multimorbidity prevalence and age-standardized mortality rates (ASMRs) in both populations were stratified by BC's health regions. Marginal structural models were used to estimate the effect of multimorbidity on mortality among PLWH, adjusted for time-varying confounders affected by prior multimorbidity.Among 8031 PLWH and 32,124 HIV-negative individuals, 25% versus 11% developed multimorbidity, and 23.53 deaths/1000 person-years (95% confidence interval [95% CI]: 22.02-25.13) versus 3.04 (2.81-3.29) were observed, respectively. PLWH in Northern region had the highest ASMR, but those in South Vancouver Island experienced the greatest difference in mortality compared with HIV-negative individuals. Among PLWH, compared with those with zero comorbidities, adjusted hazard ratios for those with 1, 2, and ≥3 comorbidities were 3.36 (95% CI: 2.86-3.95), 6.92 (5.75-8.33), and 12.87 (10.45-15.85), respectively.PLWH across BC's health regions experience excess multimorbidity and associated mortality. We highlight health disparities which are key when planning the distribution of healthcare resources across BC, and provide evidence for improved HIV care models integrating prevention and management of chronic diseases.RéSUMé: OBJECTIF: Les nouvelles thérapeutiques antirétrovirales (ARV) ont permis une plus longue espérance de vie aux personnes porteuses du VIH. Cependant, le vieillissement augmente la probabilité de développer des comorbidités au sein même de la population des personnes vivant avec le VIH (PVVIH) qui suivent des traitements ARV. On a comparé le fardeau de la multimorbidité et mortalité, toutes causes confondues, lié au statut VIH à travers la Colombie-Britannique. On a aussi évalué l’effet longitudinal de la multimorbidité sur la mortalité, toutes causes confondues, parmi les PVVIH. MéTHODES: L’étude comprit des PVVIH suivant un traitement ARV âgés de ≥19 ans et un groupe témoin séronégatif (4 témoins par PVVIH) comparable en termes d’âge et de sexe, tous provenant d’une cohorte de surveillance continue d’au moins 1 an sur une période allant de 2001 à 2012. Des diagnostics de sept comorbidités liées à l’âge ont été identifiés à partir des bases de données administratives provinciales et regroupés en 0, 1, 2 et ≥3 comorbidités. La prévalence de la multimorbidité et les taux de mortalité normalisés selon l’âge (TMNA) dans les deux populations ont été stratifiés selon les régions sociosanitaires de la Colombie-Britannique. Des modèles structurels marginaux ont été utilisés pour estimer l’effet de la multimorbidité sur la mortalité chez les PVVIH, ajustant pour les facteurs de confusion variables affectés par une multimorbidité antérieure. RéSULTATS: Parmi 8 031 PVVIH et 32 124 personnes séronégatives pour le VIH, 25 % contre 11 % ont développé une multimorbidité et 23,53 décès pour 1 000 personnes-années (intervalle de confiance à 95 % [IC à 95 %]: 22,02–25,13) contre 3,04 (2,81–3,29) ont été observés, respectivement. Les PVVIH de la région septentrionale avaient le TMNA le plus élevé, alors que ceux du sud de l’île de Vancouver ont connu la plus grande différence de mortalité par rapport aux personnes séronégatives. Parmi les PVVIH, les personnes atteintes de 1, 2 et ≥3 comorbidités avaient respectivement 3,36 (IC à 95 %: 2,86–3,95), 6,92 (5,75–8,33) et 12,87 (10,45–15,85) fois plus la probabilité de mourir que les personnes sans comorbidités. CONCLUSION: Les PVVIH des régions sociosanitaires de la Colombie-Britannique connaissent une multimorbidité excessive et la surmortalité s’y associant. Notre étude souligne les disparités-clés en matière de santé qu’il faut prendre en compte lors de la planification de la distribution des ressources de soins de santé à travers la Colombie-Britannique. Elle fournit aussi des preuves pour des modèles de soins du VIH améliorés, y intégrant la prévention et la gestion des maladies chroniques.

Objective:Food insecurity, or self-reports of inadequate food access due to limited financial resources, remains prevalent among people living with HIV (PLHIV). We examined the impact of food insecurity on combination antiretroviral therapy (cART) adherence within an integrated care programme that provides services to PLHIV, including two meals per day.Design:Adjusted OR (aOR) were estimated by generalized estimating equations, quantifying the relationship between food insecurity (exposure) and cART adherence (outcome) with multivariable logistic regression.Setting:We drew on survey data collected between February 2014 and March 2016 from the Dr. Peter Centre Study based in Vancouver, Canada.Participants:The study included 116 PLHIV at baseline, with ninety-nine participants completing a 12-month follow-up interview. The median (quartile 1–quartile 3) age was 46 (39–52) years at baseline and 87 % (n 101) were biologically male at birth.Results:At baseline, 74 % (n 86) of participants were food insecure (≥2 affirmative responses on Health Canada’s Household Food Security Survey Module) and 67 % (n 78) were adherent to cART ≥95 % of the time. In the adjusted regression analysis, food insecurity was associated with suboptimal cART adherence (aOR = 0·47, 95 % CI 0·24, 0·93).Conclusions:While food provision may reduce some health-related harms, there remains a relationship between this prevalent experience and suboptimal cART adherence in this integrated care programme. Future studies that elucidate strategies to mitigate food insecurity and its effects on cART adherence among PLHIV in this setting and in other similar environments are necessary.

Schizophrenia is a severe mental illness with important implications for morbidity and mortality. This population-based cohort study examined the impact of schizophrenia diagnoses on all-cause mortality among a sample of people living with HIV (PLHIV) and a 10% random sample of individuals living without HIV (HIV-) in British Columbia (BC), through a data linkage between the BC Centre for Excellence in HIV/AIDS and Population Data BC's data holdings. Schizophrenia diagnoses were identified via International Classification of Diseases version 9 and version 10 codes. Age- and sex-adjusted all-cause mortality rates from January 1st, 1998 to December 31st, 2012 were calculated. Multivariable logistic models assessed (1) HIV status and mortality among individuals diagnosed with schizophrenia, (2) schizophrenia diagnosis and mortality among PLHIV, and (3) correlates of mortality among PLHIV concurrently diagnosed with schizophrenia (HIV+/SZO+). From 1998 to 2012, 6.3% of those with HIV had a schizophrenia diagnosis, compared to 1.1% of those without HIV. While significant declines in mortality rates were observed throughout the study period, mortality rates were highest among HIV+/SZO+. After adjustment for substance use disorder and age at baseline, HIV+/SZO+ had a 2.64 times greater odds of mortality (95% confidence interval [CI] = 2.14–3.25) compared to HIV-/SZO+. For PLHIV, a schizophrenia diagnosis was not associated with mortality after controlling for potential confounders (adjusted odds ratio [aOR] = 0.90, 95%CI = 0.74–1.09). Among HIV+/SZO+, age, history of injection drug use, ever having an AIDS-defining illness, and never being on anti-psychotic medication or accessing psychiatric services were associated with mortality. Efforts should be made to identify and link to care individuals disproportionately affected by schizophrenia and excess mortality, including those living with HIV.

We assessed the relationship between tobacco smoking and immunologic and virologic response among people living with HIV (PLWH) initiating combination antiretroviral therapy (cART) in the Canadian HIV Observational Cohort (CANOC). Positive immunologic and virologic response, respectively, were defined as ≥50 cells/mm

IntroductionPeople living with HIV (PLHIV) are increasingly at risk of age-related comorbidities such as diabetes mellitus (DM). While DM is associated with elevated mortality and morbidity, understanding of DM among PLHIV is limited. We assessed the incidence of DM among people living with and without HIV in British Columbia (BC), Canada, during 2001–2013.MethodsWe used longitudinal data from a population-based cohort study linking clinical data and administrative health data. We included PLHIV who were antiretroviral therapy (ART) naïve at baseline, and 1:5 age-sex-matched persons without HIV. All participants had ≥5 years of historic data pre-baseline and ≥1 year(s) of follow-up. DM was identified using the BC Ministry of Health’s definitions applied to hospitalisation, physician billing and drug dispensation datasets. Incident DM was identified using a 5-year run-in period. In addition to unadjusted incidence rates (IRs), we estimated adjusted incidence rate ratios (IRR) using Poisson regression and assessed annual trends in DM IRs per 1000 person years (PYs) between 2001 and 2013.ResultsA total of 129 PLHIV and 636 individuals without HIV developed DM over 17 529 PYs and 88,672 PYs, respectively. The unadjusted IRs of DM per 1000 PYs were 7.4 (95% CI 6.2 to 8.8) among PLHIV and 7.2 (95% CI 6.6 to 7.8) for individuals without HIV. After adjustment for confounding, HIV serostatus was not associated with DM incidence (adjusted IRR: 1.03, 95% CI 0.83 to 1.27). DM incidence did not increase over time among PLHIV (Kendall trend test: p=0.9369), but it increased among persons without HIV between 2001 and 2013 (p=0.0136).ConclusionsAfter adjustment, HIV serostatus was not associated with incidence of DM, between 2001 and 2013. Future studies should investigate the impact of ART on mitigating the potential risk of DM among PLHIV.

Objective To examine the independent association between intimate partner violence (IPV) severity and all-cause mortality among women living with HIV (WLHIV). Design Cross-sectional questionnaire linked to longitudinal vital statistics data. Methods We examined the lifetime prevalence of IPV and age-standardized all-cause mortality rates by IPV severity reported by WLHIV. Lifetime IPV (emotional/verbal, physical, or sexual) severity was assessed as a categorical variable: no history of any IPV (none); experienced one or two forms of IPV (moderate); or experienced all three forms of IPV (severe IPV). Two separate logistic regression models examined associations between any IPV (vs. none) as well as IPV severity (none vs. moderate, severe) and all-cause mortality. Results At the time of interview (2007-2010), 260 participants self-identified as women with a median (Q1-Q3) age of 41 years (35-46). Of these women, the majority were unemployed (85%), 59% reported any IPV and 24% reported severe IPV. Of the 252 women followed until 31 December 2017, 25% (n = 63) died. Age-standardized all-cause mortality rates for WLHIV who experienced severe IPV were two-times higher than women with no history of IPV (44.7 per 1000 woman-years vs. 20.9 per 1000 woman-years). After adjustment for confounding, experiences of severe IPV (vs. none) were significantly associated with all-cause mortality (aOR = 2.42, 95% CI = 1.03-5.70). Conclusion Although we found that any lifetime experience of IPV was not associated with all-cause mortality, women ever experiencing severe IPV were significantly more likely to die during the study period. This may suggest a need for increased trauma- and violence-aware approaches.

Introduction Several methods have been proposed to estimate the time of HIV seroconversion, including those based on CD4 cell depletion models. However, previous models have failed to consider the heterogeneity that exists in CD4 trajectories among different sub-populations. Our objective was to estimate the time from HIV seroconversion relative to the HIV diagnosis date in a population-based cohort of people living with HIV (PLWH) in the province of British Columbia, Canada. Methods We used linked administrative and clinical data from the British Columbia Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS) cohort, which contains longitudinal individual-level data on all PLWH ever diagnosed in the province. Eligible participants were aged ≥18 years and diagnosed with HIV between 1989 and 2013. The outcome was pre-antiretroviral treatment CD4 cell count measurements assessed every six months. Models were stratified by age and stage of HIV infection at diagnosis. Several explanatory variables were considered including longitudinal viral load measurements. Longitudinal CD4, square root transformed, was modeled via a non-linear mixed effects model; time was modeled using an exponential decay function. We assumed a Gaussian distribution (identity link), an AR(1) correlation structure, and a random intercept and slope for the longitudinal viral load measurements. Due to the population variation in CD4 count among uninfected individuals, we assumed 500 to 1500 cells/mm3 as the normal range when estimating the time of HIV seroconversion. Results Longitudinal data on 1,253 individuals were analysed: 80% male, 33% White, and the median age at diagnosis was 38 years (25th-75th percentile [Q1-Q3], 31 to 45). CD4 decay differed by stage of infection at diagnosis and age, with those ≥50 years in Stages 1 and 2 experiencing a faster decline in CD4 over time. The median duration of infection from seroconversion until HIV diagnosis was 6.9 (Q1-Q3, 3.9 to 10.1) years. Conclusions Considering the heterogeneity that exists in individual CD4 cell trajectories in a population, we presented a methodology that only relies on routinely collected HIV-related data, which can be further extended to estimate other epidemic measures.

Our study aims to define and identify correlates of social isolation among people living with HIV (PLHIV). The Longitudinal Investigation into Supportive and Ancillary health services (LISA) study provided a cross-sectional analytic sample of 996 PLHIV in British Columbia, Canada (sampled between 2007 and 2010). Individuals marginalized by socio-structural inequities were oversampled; sampling bias was addressed through inverse probability of participation weighting. Through latent class analysis, three groups were identified: Socially Connected (SC) (n = 364, 37%), Minimally Isolated (MI) (n = 540, 54%) and Socially Isolated (SI) (n = 92, 9%). Correlates of the SI and MI classes, determined through multivariable multinomial regression using the SC class as a reference, include: recent violence (aOR 1.61, 95%CI 1.28-2.02 [MI vs. SC]; aOR 2.04, 95%CI 1.41-2.96 [SI vs. SC]) and a mental health diagnosis (aOR 1.50, 95% CI 1.31-1.72 [MI vs. SC]; aOR 1.43, 95%CI 1.11-1.83 [SI vs. SC]). Women (aOR 0.47; 95%CI 0.32-0.68 [SI vs. SC]), individuals of Indigenous ancestry (aOR 0.59; 95%CI 0.40-0.87 [SI vs. SC]) and people identifying as gay or lesbian (aOR 0.37; 95%CI 0.26-0.52 [SI vs. SC]) were less likely to experience isolation. These findings highlight the importance of supporting communities fostering connectedness and identifies populations susceptible to isolation.

To identify potential pathways by which a variety of factors act to lead to unsuppressed viral load.A prospective cohort of HIV-HCV co-infected adults receiving care from 18 HIV clinics across Canada was followed every 6 months between November 2012 and October 2015. Participants with at least two visits while receiving combined antiretroviral treatment (cART) were included.A path analysis was conducted on the basis of ordered sequences of multivariate logistic regressions using generalized estimating equations. The first regression model used incomplete viral suppression (viral load50 copies/ml) as the outcome of interest and all other variables (i.e. nonadherence, food insecurity, treatment attributes, and other sociodemographic, behavioural, and clinical factors) as potential predictors. Any variable determined to be a statistically significant predictor of incomplete viral suppression was then used as the next outcome of interest in the subsequent regression, until all predictors of each selected outcome were purely explanatory variables.A total of 566 participants had at least two visits. Drivers of incomplete viral suppression included injection drug use, age 45 years or less, living alone, poor health status, longer duration of HIV infection and baseline CD4 cell count less than 200 cells/μl. Nonadherence, food insecurity, and the use of multitablet regimens mediated the effects of these factors on incomplete viral suppression.Our results suggest that nonadherence, multitablet regimens, and food insecurity are key points in the pathway to incomplete HIV suppression. These are potentially amenable intervention targets that would not be revealed using traditional regression analyses.

Injection drug use (IDU) and food insecurity (FI) are highly prevalent among individuals living with HIV-hepatitis C virus (HCV) co-infection. We quantified the association between IDU and FI among co-infected individuals using biannual data from the Canadian Co-infection Cohort (N = 608, 2012-2015). IDU (in the past six months) and IDU frequency (non-weekly/weekly in the past month) were self-reported. FI (in the past six months) and FI severity (marginal FI, moderate FI, and severe FI) were measured using the Household Food Security Survey Module. Generalized estimating equations were used to estimate risk ratios (RR) quantifying the associations between IDU, IDU frequency, and FI with Poisson regression. The associations between IDU, IDU frequency, and FI severity were quantified by relative-risk ratios (RRR) estimated with multinomial regression. At the first time-point in the analytical sample, 54% of participants experienced FI in the past six months, 31% engaged in IDU in the six months preceding the FI measure, and 24% injected drugs in the past month. After adjustment for confounding, IDU in the past six months (RR = 1.15, 95% confidence interval [CI] = 1.04-1.28) as well as non-weekly (RR = 1.15, 95% CI = 1.02-1.29) and weekly IDU (RR = 1.21, 95% CI = 1.07-1.37) in the past month are associated with FI. Weekly IDU in the past month is also strongly associated with severe FI (RRR = 2.68, 95% CI = 1.47-4.91). Our findings indicate that there is an association between IDU and FI, particularly weekly IDU and severe FI. This suggests that reductions in IDU may mitigate FI, especially severe FI, in this vulnerable subset of the HIV-positive population.

OBJECTIVES The aim of this study was to determine the impact of food insecurity (FI) on HIV viral load and CD4 count among people coinfected with HIV and hepatitis C virus (HCV). METHODS This study was conducted using data from the Food Security & HIV-HCV Sub-Study of the Canadian Co-Infection Cohort study. FI was measured using the adult scale of Health Canada's Household Food Security Survey Module and was classified into three categories: food security, moderate food insecurity and severe food insecurity. The association between FI, HIV viral load, and CD4 count was assessed using a stabilized inverse probability weighted marginal structural model. RESULTS A total of 725 HIV/HCV-coinfected people with 1973 person-visits over 3 years of follow-up contributed to this study. At baseline, 23% of participants experienced moderate food insecurity and 34% experienced severe food insecurity. The proportion of people with undetectable HIV viral load was 75% and the median CD4 count was 460 [interquartile range (IQR): 300-665] cells/μL. People experiencing severe food insecurity had 1.47 times [95% confidence interval (CI): 1.14, 1.88] the risk of having detectable HIV viral load and a 0.91-fold (95% CI: 0.84, 0.98) increase in CD4 count compared with people who were food secure. CONCLUSIONS These findings provide evidence of the negative impact of food insecurity on HIV viral load and CD4 count among HIV/HCV-coinfected people.

BackgroundDespite not being collected for research purposes, linked administrative health data are increasingly being used to conduct observational epidemiologic analyses. In the field of HIV research in British Columbia (BC), Canada, the Comparative Outcomes And Service Utilization Trends (COAST) Study is based on a linkage between HIV-related clinical data and several provincial administrative health datasets. Specifically, the BC Centre for Excellence in HIV/AIDS Drug Treatment Program, which manages antiretroviral therapy (ART) dispensation for all known people living with HIV (PLWH) in BC, is linked with several Population Data BC data holdings. Population Data BC is a repository that houses longitudinal administrative data for all BC residents. RationaleWhile the use of administrative data for research poses several challenges, bias due to confounding remains to be a key issue in this context. While randomized controlled trials of ART are common, an objective of COAST is to further examine the "real-world" impact of ART on health and clinical outcomes in a population-based sample of 13,907 PLWH in BC. Therefore, while longitudinal administrative data provide a unique opportunity to estimate the effect of ART on outcomes that are infrequently assessed in trials (e.g., chronic conditions), such data often lacks information on sociodemographic, socioeconomic, and behavioural confounders. ApproachIt has been shown that adjustment for large numbers of covariates, in the form of administrative codes (e.g., diagnostic ICD codes, procedure codes, drug identification numbers), allows for better control of confounding bias. Therefore, relying on an established methodology in pharmacoepidemiology, we will use the high-dimensional propensity score algorithm to select and prioritize covariates (codes) that collectively act as proxies for unmeasured confounders. The use of this causal inference methodology in COAST will enhance our ability to generate stronger evidence to inform strategies that may improve the health and wellbeing of PLWH in this setting.

Background Despite public health messaging that antiretroviral therapy (ART) has improved health outcomes for people living with HIV (PLWH) and is effective in preventing HIV transmission, many PLWH continue to experience HIV-related stigma. It is critical to assess HIV-related stigma experienced by PLWH accessing ART in the modern HIV treatment era. Methods The STOP HIV/AIDS Program Evaluation (SHAPE) study is a longitudinal cohort of PLWH ≥19 years of age in British Columbia, Canada. This cross-sectional analysis uses SHAPE baseline survey data (collected January 2016-August 2018) and linked clinical registry data to examine factors associated with HIV-related stigma among individuals accessing ART. HIV-related stigma was self-reported using the ten-item Berger HIV stigma scale. Multivariable linear regression quantified the relationship between key explanatory variables and stigma. Results Among 627 participants, 136(22%) identified as women, 326(52%) were aged ≥50 at enrolment, 374(60%) identified as men who have sex with men, and 133(21%) self-reported Indigenous ethnicity. The median stigma score was 47.5 (Q1-Q3: 32.5-62.5; range: 0-100). In the multivariable model, reporting injection drug use (IDU) in the past year (β=4.54, 95%CI= 0.23,8.86) or selecting prefer not to answer when asked about IDU history (β=9.52, 95%CI= 4.77,14.28); experiences of lifetime violence (β=7.62, 95%CI= 3.67,11.56); and having a mental health disorder diagnosis (β=5.30, 95%CI= 1.88, 8.73) were associated with higher stigma scores. Higher stigma scores were also associated with being 40-49 years old (β= 6.21, 95%CI= 1.58,10.85) compared to Conclusion Age, city size, IDU experience, violence, and mental illness were independently associated with HIV-related stigma. These findings provide support for an intersectional investigation into how these factors propagate stigma and how this experience impacts the health and wellbeing of PLWH in this setting. Disclosure No significant relationships.

ObjectivesTo assess the impact of physicians’ patient base composition on all-cause mortality among people living with HIV (PLHIV) who initiated highly active antiretroviral therapy (HAART) in British Columbia (BC), Canada.DesignObservational cohort study from 1 January 2000 to 31 December 2013.SettingBC Centre for Excellence in HIV/AIDS’ (BC-CfE) Drug Treatment Program, where HAART is available at no cost.ParticipantsPLHIV aged ≥ 19 who initiated HAART in BC in the HAART Observational Medical Evaluation and Research (HOMER) Study.Outcome measuresAll-cause mortality as determined through monthly linkages to the BC Vital Statistics Agency.Statistical analysisWe examined the relationships between patient characteristics, physicians’ patient base composition, the location of the practice, and physicians’ experience with PLHIV and all-cause mortality using unadjusted and adjusted Cox proportional hazards models.ResultsA total of 4 445 PLHIV (median age = 42, Q1, Q3 = 34–49; 80% male) were eligible for our study. Patients were seen by 683 prescribing physicians with a median experience of 77 previously treated PLHIV in the past 2 years (Q1, Q3 = 23–170). A multivariable Cox model indicated that the following factors were associated with all-cause mortality: age (aHR = 1.05 per 1-year increase, 95% CI = 1.04 to 1.06), year of HAART initiation (2004–2007: aHR = 0.65, 95% CI = 0.53 to 0.81, 2008-2011: aHR = 0.46, 95% CI = 0.35 to 0.61, Ref: 2000–2003), CD4 cell count at baseline (aHR = 0.88 per 100-unit increase in cells/mm3, 95% CI = 0.82 to 0.94), and < 95% adherence in first year on HAART (aHR = 2.28, 95% CI = 1.88 to 2.76). In addition, physicians’ patient base composition, specifically, the proportion of patients who have a history of injection drug use (aHR = 1.11 per 10% increase in the proportion of patients, 95% CI = 1.07 to 1.15) or Indigenous ancestry (aHR = 1.07 per 10% increase , 95% CI = 1.03–1.11) and being a patient of a physician who primarily serves individuals outside of the Vancouver Coastal Health Authority region (aHR = 1.22, 95% CI = 1.01 to 1.47) were associated with mortality.ConclusionsOur findings suggest that physicians with a higher proportion of individuals who face potential barriers to care may need additional supports to decrease mortality among their patients. Future research is required to examine these relationships in other settings and to determine strategies that may mitigate the associations between the composition of physicians’ patient bases and survival.

Although an increasing number of HIV infected people are accessing antiretroviral treatment, many do not achieve complete HIV viral suppression and remain at risk for AIDS and capable of HIV transmission. Food insecurity has been identified as a potential risk factor for poor virologic response, but the association between these factors has been inconsistently documented in the literature. We systematically searched five electronic databases and bibliographies of relevant studies through April 2015 and retrieved 11 studies that met our inclusion criteria, of which nine studies were conducted in North America and the remaining two studies were in Brazil and Uganda respectively. Meta-analyzed results indicated that experiencing food insecurity resulted in 29% lower odds of achieving complete HIV viral suppression (OR = 0.71, 95% CI 0.61-0.82) and this significant inverse association was consistently found regardless of study design, exposure measurement, and confounder adjustment methods. These findings suggest that food insecurity is a potential risk factor for incomplete HIV viral suppression in people living with HIV.

Food insecurity (FI) is associated with depressive symptoms among HIV mono-infected people. Our objective was to examine to what extent this association holds among HIV–hepatitis C virus (HCV) co-infected people. We used data from a prospective cohort study of HIV–HCV co-infected people in Canada. FI was measured using the ten-item adult scale of Health Canada’s Household Food Security Survey Module and was classified into three categories: food secure, moderate FI, and severe FI. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D-10) and was classified into absence or presence of depressive symptoms. FI, depressive symptoms, and other covariates were updated every 6 months. The association between FI and depressive symptoms was assessed using a stabilized inverse probability weighted marginal structural model. The study sample included 725 HIV–HCV co-infected people with 1973 person-visits over 3 years of follow up. At baseline, 23% of participants experienced moderate food insecurity, 34% experienced severe food insecurity and 52% had depressive symptoms. People experiencing moderate FI had 1.63 times (95% CI 1.44–1.86) the risk of having depressive symptoms and people experiencing severe FI had 2.01 times (95% CI 1.79–2.25) the risk of having depressive symptoms compared to people who were food secure. FI is a risk factor for developing depressive symptoms among HIV–HCV co-infected people. Food supplementation, psychosocial support and counseling may improve patient health outcomes.

Background Severe food insecurity (FI) is common among individuals living with HIV-hepatitis C virus (HCV) co-infection. We hypothesize that the injection of opioids is partly responsible for the association between injection drug use and severe FI. Therefore, this analysis examines whether methadone maintenance treatment for opioid dependence is associated with a lower risk of severe FI. Methods We used biannual data from the Canadian Co-infection Cohort (N = 608, 2012–2015). Methadone treatment (exposure) was self-reported and severe FI (outcome) was measured using the Household Food Security Survey Module. To quantify the association between methadone treatment and severe FI, we estimated an average treatment effect on the treated (marginal risk difference [RD]) using propensity score matching. Results Among participants, 25% experienced severe FI in the six months preceding the first time-point in the analytical sample and 5% concurrently reported receiving methadone treatment. Injection of opioids in the six months preceding the treatment and outcome measurements was much higher among those who received methadone treatment (39% vs. 12%). Among the treated participants, 97% had injected opioids in their lifetimes. After propensity score matching, the average risk of experiencing severe FI is 12.3 percentage-points lower among those receiving methadone treatment, compared to those who are not receiving treatment (marginal RD = −0.123, 95% CI = −0.230, −0.015). Conclusions After adjustment for socioeconomic, sociodemographic, behavioural, and clinical confounders, methadone treatment is associated with a lower risk of severe FI. This finding suggests that methadone treatment may mitigate severe FI in this vulnerable subset of the HIV-positive population.

Severe food insecurity (FI), which indicates reduced food intake, is common among HIV-hepatitis C virus (HCV) co-infected individuals. Given the importance of unemployment as a proximal risk factor for FI, this mediation analysis examines a potential mechanism through which injection drug use (IDU) is associated with severe FI. We used biannual data from the Canadian Co-infection Cohort (N = 429 with 3 study visits, 2012–2015). IDU in the past 6 months (exposure) and current unemployment (mediator) were self-reported. Severe FI in the following 6 months (outcome) was measured using the Household Food Security Survey Module. An overall association and a controlled direct effect were estimated using marginal structural models. Among participants, 32% engaged in IDU, 78% were unemployed, and 29% experienced severe FI. After adjustment for confounding and addressing censoring through weighting, the overall association (through all potential pathways) between IDU and severe FI was: risk ratio (RR) = 1.69 (95% confidence interval [CI] = 1.15–2.48). The controlled direct effect (the association through all potential pathways except that of unemployment) was: RR = 1.65 (95% CI = 1.08–2.53). We found evidence of an overall association between IDU and severe FI and estimated a controlled direct effect that is suggestive of pathways from IDU to severe FI that are not mediated by unemployment. Specifically, an overall association and a controlled direct effect that are similar in magnitude suggests that the potential impact of IDU on unemployment is not the primary mechanism through which IDU is associated with severe FI. Therefore, while further research is required to understand the mechanisms linking IDU and severe FI, the strong overall association suggests that reductions in IDU may mitigate severe FI in this vulnerable subset of the HIV-positive population.

While research has begun addressing food insecurity (FI) in HIV-positive populations, knowledge regarding FI among individuals living with HIV-hepatitis C virus (HCV) co-infection is limited. This exploratory study examines sociodemographic, socioeconomic, behavioral, and clinical factors associated with FI in a cohort of HIV-HCV co-infected individuals in Canada. We analyzed longitudinal data from the Food Security and HIV-HCV Co-infection Study of the Canadian Co-infection Cohort collected between November 2012-June 2014 at 15 health centres. FI was measured using the Household Food Security Survey Module and classified using Health Canada criteria. Generalized estimating equations were used to assess factors associated with FI. Among 525 participants, 59 % experienced FI at their first study visit (baseline). Protective factors associated with FI (p

Background Governments require high-quality scientific evidence to prioritize resource allocation and the cost-of-illness (COI) methodology is one technique used to estimate the economic burden of a disease. However, variable cost inventories make it difficult to interpret and compare costs across multiple studies. Methods A scoping review was conducted to identify the component costs and the respective data sources used for estimating the cost of foodborne illnesses in a population. This review was accomplished by: (1) identifying the research question and relevant literature, (2) selecting the literature, (3) charting, collating, and summarizing the results. All pertinent data were extracted at the level of detail reported in a study, and the component cost and source data were subsequently grouped into themes. Results Eighty-four studies were identified that described the cost of foodborne illness in humans. Most studies (80%) were published in the last two decades (1992–2012) in North America and Europe. The 10 most frequently estimated costs were due to illnesses caused by bacterial foodborne pathogens, with non-typhoidal Salmonella spp. being the most commonly studied. Forty studies described both individual (direct and indirect) and societal level costs. The direct individual level component costs most often included were hospital services, physician personnel, and drug costs. The most commonly reported indirect individual level component cost was productivity losses due to sick leave from work. Prior estimates published in the literature were the most commonly used source of component cost data. Data sources were not provided or specifically linked to component costs in several studies. Conclusions The results illustrated a highly variable depth and breadth of individual and societal level component costs, and a wide range of data sources being used. This scoping review can be used as evidence that there is a lack of standardization in cost inventories in the cost of foodborne illness literature, and to promote greater transparency and detail of data source reporting. By conforming to a more standardized cost inventory, and by reporting data sources in more detail, there will be an increase in cost of foodborne illness research that can be interpreted and compared in a meaningful way.