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We examined correlates of late and delayed initiation of antiretroviral therapy (ART) in British Columbia, Canada. From December 2013 to December 2015 we recruited treatment-naïve people living with HIV who initiated ART within the previous year. 'Late initiation' was defined as CD4 cell count ≤500 cells/µL at ART initiation and 'delayed initiation' as ≥1 year between HIV diagnosis and initiation. Multivariable logistic regression assessed independent correlates of late and delayed initiation. Of 87 participants, 44 (51%) initiated late and 22 (26%) delayed initiation. Delayed initiation was positively associated with older age (adjusted odds ratio [AOR]: 1.06 per year, 95% confidence interval [95% CI]: 1.01-1.12) and inversely associated with wanting to start ART at diagnosis (AOR: 0.06, 95% CI: 0.02-0.21). Variables associated with late initiation were older age (AOR: 1.09 per year, 95% CI: 1.03-1.15) and medical reason(s) for initiation (AOR: 5.00, 95% CI: 1.41-17.86). Late initiation was less likely among those with greater perceived ART efficacy (AOR 0.94, 95% CI: 0.90-0.98) and history of incarceration (AOR: 0.12, 95% CI: 0.03-0.56). Disparities in timing of initiation were observed for age, perceived ART efficacy, and history of incarceration. Enhanced health services that address these factors may facilitate earlier treatment initiation.

Introduction: People who use drugs are disproportionally affected by sexually transmitted and blood‐borne infections (STBBIs). While the benefits of methadone in reducing injecting‐risk behaviours are well documented, less is known on its impacts on sexual‐related risks, as well as its comparative effectiveness to buprenorphine/naloxone, particularly in the context of highly potent opioids. The aim of this study was to estimate the relative effects of buprenorphine/naloxone and methadone on injecting and STBBI risks among people with prescription‐type opioid use disorder (POUD). Methods: Secondary analysis of a pan‐Canadian pragmatic 24‐week randomized clinical trial comparing methadone and buprenorphine/naloxone models of care among 272 people with POUD (including licit or illicit opioid analgesics, fentanyl). The Risk Behaviour Survey was used to collect injecting and sexual risks at baseline, and weeks 12 and 24. Results: In total, 210 participants initiated treatment (103 buprenorphine/naloxone and 107 methadone). At baseline, 113/205 (55.1%) participants reported recently injecting drugs, 37/209 (17.7%) unsafe injection practices and 67/162 (41.4%) high‐risk sex. Both methadone and buprenorphine/naloxone were associated with reductions in the prevalence of injection drug use and high‐risk sex at weeks 12 and 24 with no interactions between treatment arm and time. Conclusion: Methadone and buprenorphine/naloxone were similarly effective in reducing injecting and sexual risk behaviours among people with POUD. Clinical Trials Registration: clinicaltrials.gov NCT03033732. [ABSTRACT FROM AUTHOR]

IntroductionAmong gay, bisexual, and other men who have sex with men (GBM), collinearity between polysubstance use and mental health concerns has obscured their combined effects on HIV risk with multivariable results often highlighting only one or the other.MethodsWe used mediation and moderation analyses to examine the effects of polysubstance use and depressive symptoms on high-risk sex (i.e., condomless anal sex with serodiscordant/unknown status partner) in a sample of sexually-active GBM, aged ≥16 years, recruited in Metro Vancouver using respondent driven sampling. Hospital Anxiety and Depression Scale scores assessed mental health. Alcohol Use Disorder Identification Test scores assessed alcohol disorders. Poly-use of multiple drug types (e.g., stimulants, sedatives, opiates, hallucinogens) was assessed over the previous six months.ResultsAmong 719 predominantly white (68.0%), gay-identified (80.7%) GBM, alcohol use was not associated with increased prevalence of high-risk sex. Controlling for demographic factors and partner number, an interaction between polysubstance use and depressive symptoms revealed that the combined effects were additively associated with increased odds for high-risk sex. Mediation models showed that polysubstance use partially mediated the relationship between depressive symptoms and high-risk sex.ConclusionAn interaction effect between polysubstance use (defined by using 3 or more substances in the past six months) and depressive symptoms (defined by HADS scores) revealed that the combination of these factors was associated with increased risk for high-risk sex - supporting a syndemic understanding of the production of HIV risk.

BackgroundStudies have found that gay, bisexual, and other men who have sex with men (GBM) have higher rates of mental health conditions and substance use than heterosexual men, but are limited by issues of representativeness.ObjectivesTo determine the prevalence and correlates of mental health disorders among GBM in Metro Vancouver, Canada.MethodsFrom 2012 to 2014, the Momentum Health Study recruited GBM (≥16 years) via respondent-driven sampling (RDS) to estimate population parameters. Computer-assisted self-interviews (CASI) collected demographic, psychosocial, and behavioral information, while nurse-administered structured interviews asked about mental health diagnoses and treatment. Multivariate logistic regression using manual backward selection was used to identify covariates for any lifetime doctor diagnosed: (1) alcohol/substance use disorder and (2) any other mental health disorder.ResultsOf 719 participants, 17.4% reported a substance use disorder and 35.2% reported any other mental health disorder; 24.0% of all GBM were currently receiving treatment. A lifetime substance use disorder diagnosis was negatively associated with being a student (AOR = 0.52, 95% CI [confidence interval]: 0.27-0.99) and an annual income ≥$30,000 CAD (AOR = 0.38, 95% CI: 0.21-0.67) and positively associated with HIV-positive serostatus (AOR = 2.54, 95% CI: 1.63-3.96), recent crystal methamphetamine use (AOR = 2.73, 95% CI: 1.69-4.40) and recent heroin use (AOR = 5.59, 95% CI: 2.39-13.12). Any other lifetime mental health disorder diagnosis was negatively associated with self-identifying as Latin American (AOR = 0.25, 95% CI: 0.08-0.81), being a refugee or visa holder (AOR = 0.18, 95% CI: 0.05-0.65), and living outside Vancouver (AOR = 0.52, 95% CI: 0.33-0.82), and positively associated with abnormal anxiety symptomology scores (AOR = 3.05, 95% CI: 2.06-4.51).ConclusionsMental health conditions and substance use, which have important implications for clinical and public health practice, were highly prevalent and co-occurring.

Background The overdose crisis in North America has prompted system-level efforts to restrict opioid prescribing for chronic pain. However, little is known about how discontinuing or tapering prescribed opioids for chronic pain shapes overdose risk, including possible differential effects among people with and without concurrent opioid use disorder (OUD). We examined associations between discontinuation and tapering of prescribed opioids and risk of overdose among people on long-term opioid therapy for pain, stratified by diagnosed OUD and prescribed opioid agonist therapy (OAT) status. Methods and findings For this retrospective cohort study, we used a 20% random sample of residents in the provincial health insurance client roster in British Columbia (BC), Canada, contained in the BC Provincial Overdose Cohort. The study sample included persons aged 14 to 74 years on long-term opioid therapy for pain ([greater than or equal to]90 days with [greater than or equal to]90% of days on therapy) between October 2014 and June 2018 (n = 14,037). At baseline, 7,256 (51.7%) persons were female, the median age was 55 years (quartile 1-3: 47-63), 227 (1.6%) persons had been diagnosed with OUD (in the past 3 years) and recently (i.e., in the past 90 days) been prescribed OAT, and 483 (3.4%) had been diagnosed with OUD but not recently prescribed OAT. The median follow-up duration per person was 3.7 years (quartile 1-3: 2.6-4.0). Marginal structural Cox regression with inverse probability of treatment weighting (IPTW) was used to estimate the effect of prescribed opioid treatment for pain status (discontinuation versus tapered therapy versus continued therapy [reference]) on risk of overdose (fatal or nonfatal), stratified by the following groups: people without diagnosed OUD, people with diagnosed OUD receiving OAT, and people with diagnosed OUD not receiving OAT. In marginal structural models with IPTW adjusted for a range of demographic, prescription, comorbidity, and social-structural exposures, discontinuing opioids (i.e., [greater than or equal to]7-day gap[s] in therapy) was associated with increased overdose risk among people without OUD (adjusted hazard ratio [AHR] = 1.44; 95% confidence interval [CI] 1.12, 1.83; p = 0.004), people with OUD not receiving OAT (AHR = 3.18; 95% CI 1.87, 5.40; p < 0.001), and people with OUD receiving OAT (AHR = 2.52; 95% CI 1.68, 3.78; p < 0.001). Opioid tapering (i.e., [greater than or equal to]2 sequential decreases of [greater than or equal to]5% in average daily morphine milligram equivalents) was associated with decreased overdose risk among people with OUD not receiving OAT (AHR = 0.31; 95% CI 0.14, 0.67; p = 0.003). The main study limitations are that the outcome measure did not capture overdose events that did not result in a healthcare encounter or death, medication dispensation may not reflect medication adherence, residual confounding may have influenced findings, and findings may not be generalizable to persons on opioid therapy in other settings. Conclusions Discontinuing prescribed opioids was associated with increased overdose risk, particularly among people with OUD. Prescribed opioid tapering was associated with reduced overdose risk among people with OUD not receiving OAT. These findings highlight the need to avoid abrupt discontinuation of opioids for pain. Enhanced guidance is needed to support prescribers in implementing opioid therapy tapering strategies with consideration of OUD and OAT status., Author(s): Mary Clare Kennedy 1,2,*, Alexis Crabtree 3, Seonaid Nolan 1,4, Wing Yin Mok 1, Zishan Cui 1,3, Mei Chong 5, Amanda Slaunwhite 3,5, Lianping Ti 1,4 Introduction Canada and [...]

: Introduction: Treatment as prevention strategies have been variously applied across provinces in Canada. We estimated HIV care cascade indicators and correlates of unsuppressed viral load (VL) among gay, bisexual and other men who have sex with men (GBM) recruited in Vancouver, Toronto and Montreal. Methods: Sexually active GBM, aged ≥16 years, were recruited through respondent‐driven sampling (RDS) from February 2017 to August 2019. Participants completed a Computer‐Assisted Self‐Interview and tests for HIV and other sexually transmitted infections (STIs). We conducted bivariate analyses comparing RDS‐adjusted proportions across cities. We used multivariable logistic regression to examine factors associated with having a measured VL ≥ 200 copies/mL with data pooled from all three cities. Results: We recruited 1179 participants in Montreal, 517 in Toronto and 753 in Vancouver. The RDS‐adjusted HIV prevalence was 14.2% (95% CI 11.1 to 17.2) in Montreal, 22.1% (95% CI 12.4 to 31.8) in Toronto and 20.4% (95% CI 14.5 to 26.3) in Vancouver (p < 0.001). Of participants with confirmed HIV infection, 3.3% were previously undiagnosed in Montreal, 3.2% undiagnosed in Toronto and 0.2% in Vancouver (p = 0.154). In Montreal, 87.6% of GBM living with HIV were receiving antiretroviral therapy (ART) and 10.6% had an unsuppressed VL; in Toronto, 82.6% were receiving ART and 4.0% were unsuppressed; in Vancouver, 88.5% were receiving ART and 2.6 % were unsuppressed (p < 0.001 and 0.009 respectively). Multivariable modelling demonstrated that participants in Vancouver (adjusted odds ratio [AOR]=0.23; 95% CI 0.06 to 0.82), but not Toronto (AOR = 0.27; 95% CI 0.07 to 1.03), had lower odds of unsuppressed VL, compared to Montreal, as did older participants (AOR 0.93 per year; 95% CI 0.89 to 0.97), those at high‐risk for hazardous drinking (AOR = 0.19; 95% CI 0.05 to 0.70), those with a primary care provider (AOR = 0.11; 95% CI 0.02 to 0.57), and those ever diagnosed with other STIs (AOR = 0.12; 95% CI 0.04 to 0.32). Conclusions: GBM living in Montreal, Toronto and Vancouver are highly engaged in HIV testing and treatment and all three cities have largely achieved the 90‐90‐90 targets for GBM. Nevertheless, we identified disparities which can be used to identify GBM who may require additional interventions, in particular younger men and those who are without a regular primary care provider., INTRODUCTION Gay, bisexual and other men who have sex with men (GBM) in Canada are disproportionately affected by HIV and other sexually transmitted infections (STIs). In 2016, GBM accounted for [...]