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Sophia Dobischok,1 Rebecca K Metcalfe,1 Elizabeth Angela Matzinger,1 Kurt Lock,1,2 Scott Harrison,3 Scott MacDonald,3 Sherif Amara,4 Martin T Schechter,1,5 Nick Bansback,1,5 Eugenia Oviedo-Joekes1,5 1Centre for Health Evaluation & Outcome Sciences, Providence Health Care, Vancouver, BC, Canada; 2BC Centre for Disease Control, Provincial Health Services Authority, Vancouver, BC, Canada; 3Providence Health Care, Providence Crosstown Clinic, Vancouver, BC, Canada; 4SafePoint Supervised Consumption Site, Fraser Health Authority, Surrey, BC, Canada; 5School of Population and Public Health, University of British Columbia, Vancouver, BC, CanadaCorrespondence: Eugenia Oviedo-Joekes, Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, 575-1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada, Tel +1 604-682-2344 Ext. 62973, Fax +1-604-806-8210, Email eugenia.joekes@ubc.caPurpose: Injectable opioid agonist treatment (iOAT) is an effective treatment for opioid use disorder (OUD). To our knowledge, no research has systematically studied client preferences for accessing iOAT. Incorporating preferences could help meet the heterogenous needs of clients and make addiction care more person-centred. This paper presents a pilot study of a best-worst scaling (BWS) preference elicitation survey that aimed to assess if the survey was feasible and accessible for our population and to test that the survey could gather sound data that would suit our planned analyses.Patients and Methods: Current and former iOAT clients (n = 18) completed a BWS survey supported by an interviewer using a think-aloud approach. The survey was administered on PowerPoint, and responses and contextual field notes were recorded manually. Think-aloud audio was recorded on Audacity.Results: Clients’ feedback fell into five categories: framing of the task, accessibility, conceptualization of attributes and levels, formatting, and behaviour predicting questions. Survey repetitiveness was the most consistent feedback. The data simulation showed that 100 responses should provide an adequate sample size.Conclusion: This pilot demonstrates the type of analysis that can be done with BWS in our population, suggests that such analysis is feasible, and highlights the importance of the interviewer and participant working side-by-side throughout the task.Keywords: opioid use disorder, opioid agonist treatment, injectable opioid agonist treatment, diacetylmorphine, hydromorphone, best worst scaling

INTRODUCTION AND AIMS Illicit stimulant use is prevalent among patients receiving injectable opioid agonist treatment (iOAT) and has been associated with early treatment discontinuation and illicit opioid use. Despite these concerns, little is known about the use of illicit stimulants in this population. As such, this study aimed to explore the processes by which patients receiving iOAT engage in the use of illicit stimulants. DESIGN AND METHODS One-on-one in-depth qualitative interviews were conducted. Data collection and analysis followed an iterative approach of coding, searching for meaning, and returning to data collection to saturate categories and explicate relationships between them. Participants were patients receiving iOAT in Vancouver, Canada that reported the use of illicit stimulants (n = 31). RESULTS The process of 'self-managing illicit stimulant use' was constructed from the data. This process was made up of three interrelated categories reflecting participants' engagement in illicit stimulant use: (i) distancing from the street environment; (ii) taking control of use; and (iii) mobilising support (clinical and social). DISCUSSION AND CONCLUSIONS For patients with opioid use disorder and concurrent stimulant use disorder, access to iOAT can promote the self-management of illicit stimulant use. Daily visits to the clinic for opioid agonist treatment present an important opportunity to offer services and supports for patients who use illicit stimulants. Interventions can be guided by patients, recognising them as experts in the management of their stimulant use.

OBJECTIVE Patient ratings of physician communication in the setting of daily injectable opioid agonist treatment are reported. Associations between communication items and demographic, health, drug use, and treatment characteristics are explored. METHODS Participants (n = 121) were patients receiving treatment for opioid use disorder with hydromorphone (an opioid analgesic) or diacetylmorphine (medical grade heroin). Ratings of physician communication were collected using the 14-item Communication Assessment Tool. Items were dichotomized and associations were explored using univariate and multivariable logistic regression models for each of the 14 items. RESULTS Ratings of physician communication were lower than reported in other populations. In nearly all of the 14 multivariable models, participants with more physical health problems and with lower scores for treatment drug liking had lower odds of rating physician communication as excellent. CONCLUSIONS In physician interactions with patients with opioid use disorder, there is a critical need to address comorbid physical health problems and account for patient medication preferences. PRACTICE IMPLICATIONS Findings reinforce the role physicians can play in communicating with patients about their comorbid conditions and about medication preferences. In the patient-physician interaction efforts to meet patients' evolving treatment needs and preferences can be made by offering patients access to all available evidence-based treatments.

From 1986 to 2006, Northern Uganda experienced an atrocious civil war between the Lord's Resistance Army (LRA) and the Ugandan government. Acholi people living in the region continue to be impacted by trauma sequelae of the war and a wide range of daily stressors including poverty, hunger, and high rates of HIV infection. To date, there is a dearth of gender-differentiated mental health research in this post-conflict setting. The current study aimed to estimate the prevalence of probable post-traumatic stress disorder (PTSD) and depression in three districts most affected by the Northern Ugandan conflict and examine socio-structural, war-related, and sexual vulnerability factors associated with mental health.Cango Lyec (Healing the Elephant) is an open cohort study involving participants from eight randomly selected communities in Amuru, Gulu, and Nwoya districts of Northern Uganda. Between November 2011 and July 2012, the baseline cohort (The overall prevalence of probable PTSD and depression was 11.7% and 15.2% respectively. Among former abductees, the prevalence was 23.2% for probable PTSD and 26.6% for probable depression. Women were significantly more likely to experience mental distress than men. Factors associated with mental distress included wartime trauma (adjusted odds ratios ranging from 2.80 to 7.19), experiences of abduction (adjusted odds ratios ranging from 1.97 to 3.03), and lack of housing stability and safety (adjusted odds ratios ranging from 1.95 to 4.59). Additional risk factors for women included HIV infection (AOR=1.90; 95% CI: 1.29-2.80), sexual abuse in the context of war (AOR=1.58; 95% CI: 1.02-2.45), and intimate partner violence (AOR=2.45; 95% CI: 1.07-5.63).Cango Lyec participants displayed lower than previously reported yet significant levels of probable PTSD and depression. Based on findings from this study, providing trauma-informed care, ensuring food and housing security, eliminating gender-based violence, and reintegrating former abductees remain important tasks to facilitate post-conflict rehabilitation in Northern Uganda.

Background A high proportion of people receiving both oral and injectable opioid agonist treatment report concurrent use of stimulants (i.e. cocaine and or amphetamines), which has been associated with higher rates of continued illicit opioid use and treatment dropout. A recent randomized controlled trial demonstrated the effectiveness of dextroamphetamine (a prescribed stimulant) at reducing craving for and use of cocaine among patients receiving injectable opioid agonist treatment. Following this evidence, dextroamphetamine has been prescribed to patients with stimulant use disorder at a clinic in Vancouver. This study investigates perceptions of the effectiveness of dextroamphetamine from the perspective of these patients. Methods Data were collected using small focus groups and one-on-one interviews with patients who were currently or formerly receiving dextroamphetamine (n = 20). Thematic analysis was conducted using an iterative approach, moving between data collection and analysis to search for patterns in the data across transcripts. This process led to the defining and naming of three central themes responding to the research question. Results Participants reported a range of stimulant use types, including cocaine (n = 8), methamphetamine (n = 8), or both (n = 4). Three central themes were identified as relating to participants’ perceptions of the effectiveness of the medication: 1) achieving a substitution effect (i.e. extent to which dextroamphetamine provided a substitution for the effect they received from use of illicit stimulants); 2) Reaching a preferred dose (i.e. speed of titration and effect of the dose received); and 3) Ease of medication access (i.e. preference for take home doses (i.e. carries) vs. medication integrated into care at the clinic). Conclusion In the context of continued investigation of pharmacological treatments for stimulant use disorder, the present study has highlighted how the study of clinical outcomes could be extended to account for factors that contribute to perceptions of effectiveness from the perspective of patients. In practice, elements of treatment delivery (e.g. dosing and dispensation protocols) can be adjusted to allow for various scenarios (e.g. on site vs. take home dosing) by which dextroamphetamine and other pharmacological stimulants could be implemented to provide “effective” treatment for people with a wide range of treatment goals and needs.

ObjectivesThis study examined associations between childhood maltreatment, colonial harms and sex/drug-related risks for HIV and hepatitis C virus (HCV) infection among young Indigenous people who use drugs.DesignThe Cedar Project is a cohort involving young Indigenous people who use drugs in British Columbia (BC), Canada. Indigenous collaborators, collectively known as the Cedar Project Partnership, govern the entire research process.SettingVancouver is a large city on the traditional territory of the Coast Salish peoples. Prince George is a mid-sized city, on the traditional territory of Lheidli T’enneh First Nation.Participants420 participants completed the Childhood Trauma Questionnaire and returned for follow-up from 2003 to 2016.Primary/secondary outcome measuresPrimary outcomes were HIV and HCV infection over the study period. Secondary outcomes included sex and substance use-related risks.ResultsPrevalence of childhood maltreatment was 92.6% experienced any maltreatment; 73.4% experienced emotional abuse; 62.6% experienced physical abuse; 60.3% experienced sexual abuse; 69.5% experienced emotional neglect and 79.1% experienced physical neglect. We observed significant associations between childhood maltreatment and apprehensions into residential schools and foster care. All maltreatment types were associated with higher odds of sex/substance use-related risks; sexual abuse was associated with higher odds of HCV infection (adjusted OR: 1.67; 95% CI 1.05 to 2.66; p=0.031).ConclusionsFindings reflect high prevalence of childhood maltreatment and their associations with HIV/HCV risk and HCV infection. Public health prevention and treatment initiatives must be trauma informed and culturally safe to support healing, health, and well-being.

Supplemental Digital Content is available in the text, Objectives: The present study aims to describe a 3-day induction protocol for injectable hydromorphone (HDM) and diacetylmorphine (DAM) used in 3 Canadian studies and examine rates of opioid-related overdose and somnolence during this induction phase. Methods: The induction protocol and associated data on opioid-related overdose and somnolence are derived from 2 clinical trials and one cohort study conducted in Vancouver and Montreal (2005–2008; 2011–2014; 2014–2018). In this analysis, using the Medical Dictionary for Regulatory Activities coding system we report somnolence (ie, drowsiness, sleepiness, grogginess) and opioid overdose as adverse events. Overdoses requiring intervention with naloxone are coded as severe adverse events. Results: Data from the 3 studies provides a total of 1175 induction injections days, with 700 induction injection days for DAM, and 475 induction injection days for HDM. There were 34 related somnolence and adverse event (AE) overdoses (4.899 per 100 injection days) in DAM and 6 (1.467 per 100 days) in HDM. Four opioid overdoses requiring naloxone (0.571 per 100 injection days) were registered in DAM and 1 in HDM (0.211 per 100 injection days), all safely mitigated onsite. The first week maximum daily dose patients received were on average 433.62 mg [standard deviation (SD) = 137.92] and 223.26 mg (SD = 68.06) for DAM and HDM, respectively. Conclusions: A 3-day induction protocol allowed patients to safely reach high doses of injectable hydromorphone and diacetylmorphine in a timely manner. These findings suggest that safety is not an evidence-based barrier to the implementation of treatment with injectable hydromorphone and diacetylmorphine.

Indigenous leaders are gravely concerned over disproportionate representation of Indigenous children in Canada’s child welfare systems. Forced separation from children is deeply traumatizing for mothers and detrimental to the wellbeing of Indigenous families, communities and Nations. This study examined relationships between child apprehension and suicide attempt within a cohort of young Indigenous women impacted by substance use. We utilized data collected every 6 months (2008–2016) by the Cedar Project, an Indigenous-governed cohort study involving young Indigenous people who use drugs in British Columbia, Canada. Recent child apprehension was defined as having a child apprehended by the Ministry of Child and Family Development since last visit. Recurrent event Cox proportional hazards models estimated the independent effect of child apprehension on maternal suicide attempt. Among 293 participants, 78 (27%) reported 136 child apprehensions; incidence of first apprehension was 6.64 (95%CI: 5.25–8.29) per 100 person-years. Forty-seven (16%) participants reported 75 suicide attempts with an incidence of 4.00 (95%CI: 2.94–5.33) per 100 person-years. Participants who reported recent child apprehension (HR: 1.88, 95%CI: 1.00–3.55), had a parent attend residential school (HR: 4.12, 95%CI: 1.63–10.46), experienced recent sexual assault (HR: 4.04, 95%CI: 2.04–7.99), violence (HR: 2.54, 95%CI: 1.52–4.27) or overdose (HR: 4.97, 95%CI: 2.96–8.35) were more likely to attempt suicide. Participants who had a traditional language spoken in the home growing up were half as likely to attempt suicide (HR: 0.49, 95%CI: 0.23–1.01). Results suggest that child welfare systems in Canada perpetuate historical and intergenerational trauma among young Indigenous mothers. Indigenous self-determination over child welfare and culturally safe services are urgently needed to end cycles of child apprehension and support the wellbeing of families, communities and Nations.

Background The legacy of war in Northern Uganda continues to impact people’s health and wellbeing in the Acholi region. Despite increasing attention to Hepatitis B Virus (HBV) in Uganda and globally, concerns remain that unique drivers of infection, and barriers to screening, and treatment, persist among those affected by conflict. Methods Cango Lyec (Healing the Elephant) cohort survey involved conflict-affected adults aged 13–49 in three mid-Northern Uganda districts (Gulu, Amuru and Nwoya). Baseline (2011–2012) samples were tested for HBV surface antigen (HBsAg), HBV e-antigen (HBeAg), antibodies to HBV surface antigen (HBsAb), antibodies to HBV e-antigen (HBeAb), and antibodies to HBV core antigen (HBcAb). All HBsAg positive samples were tested for IgM antibodies to HBV B core antigen (HBc-IgM) and where available, >6-month follow-up samples were tested for HBeAg and HBV DNA. Data were analyzed using STATA 15 software. Logistic regression accounted for variance due to complex two-stage sampling that included stratification, unequal selection probabilities and community clustering. Odds ratios measured effect potential risk factors associated with chronic HBV infection. Results Among 2,421 participants, 45.7% were still susceptible to HBV infection. HBsAg seropositivity was 11.9% (10.9–13.0), chronic HBV was 11.6% (10.4–12.8), acquired immunity resulting from vaccination was 10.9%, and prior natural infection was 31.5%. Older age (OR:0.570; 95%CI:0.368–0.883) and higher education (OR:0.598; 95%CI:0.412–0.868) were associated with reduced odds of chronic HBV infection. Being male (OR:1.639; 95%CI:1.007–2.669) and having been abducted (OR:1.461; 95%CI:1.055–2.023) were associated with increased odds of infection. Among women, having 1 or 2 pregnancies (compared to none or >2) was associated with increased odds of infection (OR:1.764; 95%CI:1.009–3.084). Conclusion Chronic HBV is endemic in Gulu, Amuru and Nwoya districts. Recommended strategies to reduce post-conflict prevalence include establishment of Northern Uganda Liver Wellness Centres, integration of screening and treatment into antenatal care, and roll out of birth-dose vaccination.

Background Patients' perceptions are vital to the delivery and evaluation of substance use treatment. They are most frequently collected at one time-point and measured using patient satisfaction questionnaires or qualitative methodologies. Interestingly, the findings of these studies often diverge, as satisfaction scores tend to be highly positive, while qualitative findings suggest dissatisfaction and areas for improvement. This divergence limits current understandings of patients' perceptions and their potential change over time in treatment. Objective This study explores the relationship between open-ended positive and negative perceptions of treatment and patient satisfaction scores over time. Methods The RUTH (Research on the Utilization of Therapeutic Hydromorphone) prospective cohort study included 131 participants receiving injectable diacetylmorphine or hydromorphone in Canada's first injectable opioid agonist treatment (iOAT) program. The study collected the Client Satisfaction Questionnaire (CSQ-8) at eight time-points over an 18-month period. Following a multi-methods approach, the study complemented the CSQ-8 with open-ended positive and negative comments of iOAT. The research team analyzed these comments thematically at each time-point to develop positive and negative perception themes. We then used growth curve modeling to explore the relationship between positive and negative perception themes and patient satisfaction over time. Findings Over the eight time-points, six positive and eight negative perception themes emerged, broadly reflecting structural (e.g., expansion of iOAT), process (e.g., schedules), relational (e.g., interactions with providers), and outcome-related (e.g., met/unmet needs) perceptions of iOAT. On average, participants reported high satisfaction (grand mean = 29.2 out of 32), and scores did not significantly change over time. However, we did find significant unexplained variation within participants in their satisfaction trajectories and between participants in their initial satisfaction scores. In conditional growth curve models, the theme “unfavorable interactions with providers” had the strongest independent effect on overall satisfaction trajectories. Conclusions This study provides an example of how open-ended comments can be integrated with patient satisfaction questionnaire data to gather a comprehensive and patient-centered evaluation of substance use treatment. Considering the iOAT context specifically, relational dynamics and daily treatment access were significant predictors of patient satisfaction over time and may be attributes of iOAT that require further investigation.

Cocaine use is prevalent among people receiving injectable opioid agonist treatment. Investigations of cocaine use in this population have been descriptive and the potential heterogeneity existing in patterns of use have not been characterized. As such, among patients receiving injectable opioid agonist treatment, this study aimed to: 1) quantify intra- and inter-individual variation in cocaine use over 24-months and; 2) determine how predictors of interest explained this variation.Participants were patients receiving injectable opioid agonist treatment for opioid use disorder. Study visits were completed at baseline prior to receiving treatment, and 3,6,9,12,18, and 24 months after baseline. A multi-level regression approach to growth curve modeling was employed to estimate and explain intra- (within-person) and inter-individual (between-person) variation in cocaine use.Significant intra and inter-individual variation in cocaine use was identified over 24-months. Treatment engagement was on average associated with reductions in the prior month number of days of cocaine use (range: 0-30)(Estimate (standard error): -0.05(0.02), p = 0.003). On average, men reported less cocaine use compared to women (Estimate (standard error): -5.91(1.57), p=0.001), and participants reporting ever regularly using cocaine at baseline reported more cocaine use over 24-months compared to participants reporting never regularly using cocaine (Estimate (standard error): 4.72 (1.91), p = 0.013).Significant reductions in cocaine use were observed and significant heterogeneity in patterns of cocaine use was identified. These heterogeneous cocaine use profiles suggest that an individualized approach to care will be critical in responding to patients' cocaine use in injectable opioid agonist treatment.

Background Injectable opioid agonist treatment (iOAT) was designed as a pragmatic and compassionate approach for people who have not benefitted from medication assisted treatment with oral opioids (e.g., methadone). While, a substantial body of clinical trial evidence has demonstrated the safety and effectiveness of iOAT, considerably less is known about the patient-centered aspects of this treatment and their role in self-reported treatment goals and outcomes. The aim of this study was to explore participants’ experiences in iOAT as they broadly relate to the domains of patient-centered care. A secondary goal was to explore how these experiences affected participants’ self-reported treatment outcomes. Methods A qualitative methodology, and constructivist grounded theory approach, was used to guide sampling, data collection and analysis. A total of 30 in-depth interviews were conducted with people receiving iOAT in North America’s first clinic. Audio-recordings for each semi-structured interview were transcribed and read repeatedly. The strategy of constant comparison was used through iterative stages of line-by-line, focused and theoretical coding until theoretical saturation was achieved. Results “Building healthcare provider relationships for patient-centered care in iOAT” was the emergent core concept. Healthcare provider relationships were established through two interrelated processes: ‘Opening up’ was attributed to the positive environment, and to feeling understood and supported by healthcare providers. ‘Being a part of care’ emerged as participants felt safe to ask for what was needed and had opportunities to collaborate in treatment decisions. These processes established a foundation in which participants experienced care that was responsive to their individual dose, health and psychosocial needs. Conclusions The core concept suggested that therapeutic relationships were fundamental to experiences of patient-centered care in iOAT. When relationships were respectful and understanding, participants received individualized and holistic care in iOAT. These findings offer a valuable example of how therapeutic relationships can be strengthened in other substance use treatment settings, particularly when responding to the diverse treatment needs of clients.

Background: As previously encamped resettle, potential for rapid HIV transmission in post-conflict Northern Uganda is concerning. Women in particular may be experiencing heightened vulnerability resulting from war-related sexual violence. Setting: Cango Lyec (Healing the Elephant) Project is a cohort involving conflict-affected people in 3 districts in Northern Uganda. Methods: Eight randomly selected communities were mapped, and a census was conducted. Participants aged 13–49 years completed questionnaires in Luo on war-related experiences, mental health, sexual vulnerabilities, and sociodemographics. Blood samples were tested for HIV and syphilis. Baseline data from all sexually active participants was used to determine gender differences in HIV prevalence. Multivariate modeling determined correlates of HIV by gender. Results: Among 2008 participants, HIV prevalence was higher among women [17.2; 95% confidence interval (CI): 14.7 to 19.7] compared to men (10.6; 95% CI: 8.0 to 13.2

Introduction and Aims. To determine the effectiveness of injectable hydromorphone and dicaetylmorphine for Indigenous participants in the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) clinical trial. The study additionally aims to explore the prevalence and frequency of crack cocaine use among subgroups of participants (by gender and ethnicity). This secondary analysis is particularly relevant given the current need for expanded medication assisted treatments for opioid dependence across North America. Design and Methods. Participants self-identifying as First Nations, Metis or Inuit were included in the analysis of Indigenous participants. Six-month treatment outcomes are reported as the difference between diacetylmorphine and hydromorphone treatment arms among Indigenous participants and change from baseline to 6 months in each treatment arm. Differences in outcomes are tested between Indigenous and non-Indigenous participants. Crack cocaine use was explored to determine differences between and within subgroups. Results. Approximately one-third of SALOME participants self-identified as Indigenous. Indigenous participants presented to treatment with more structural vulnerabilities (e.g. lower education, higher rates of foster care and separation from biological parents) compared to non-Indigenous participants. After 6 months, Indigenous participants in both treatment arms had a significant reduction in days of street heroin use, opioid use, crack cocaine use and illegal activity. Treatment retention did not differ by treatment arm. Discussion and Conclusions. Indigenous people that are not engaged by first-line treatments for opioid dependence are in need of effective alternative treatments. Given the political and logistical barriers facing diacetylmorphine, hydromorphone could serve as a more accessible medication to reach and treat this population. [Oviedo-Joekes E, Palis H, Guh D, Marchand K, Brissette S, Lock K, MacDonald S, Harrison S, Anis AH, Krausz M, March DC, Schechter MT. Characteristics and response to treatment among Indigenous people receiving injectable diacetylmorphine or hydromorphone in a randomised controlled trial for the treatment of long-termopioid dependence. Drug Alcohol Rev 2017;00:000-000]

Objective: This study aims to examine factors associated with suicidal ideation among people with opioid dependence and to explore whether these factors are gender-specific. Methods: Cross-sectional data were collected among long-term opioid-dependent individuals ( n = 176; 46.0% women). Lifetime histories of suicidal ideation were measured using the Composite International Diagnostic Interview, and additional data were collected regarding sociodemographic characteristics, drug use, health, and adverse life events. Multivariable logistic regression was used to determine the relationships between these variables and suicidal ideation for the full study sample and separately for women and men to explore the potential role of gender. Results: A total of 43.8% ( n = 77) of participants reported a lifetime history of suicidal ideation. Among those with suicidal ideation, 49.3% were women and the overall average age of first ideation was 19.82 years (SD, 11.66 years). Results from multivariable analyses showed that a history of depression, anxiety, and childhood emotional neglect and the number of lifetime traumatic events were significantly associated with higher odds of suicidal ideation. The gender-based analysis suggested that histories of depression and anxiety remained independently associated with lifetime suicidal ideation among women, whereas for men, childhood emotional neglect and the number of lifetime potentially traumatic events were independently associated with lifetime suicidal ideation. Conclusions: This study offers a critical first step to understanding factors associated with suicidal ideation among long-term opioid-dependent men and women and the potential importance of gender-sensitive approaches for suicidal behavior interventions. These data inform further research and clinical opportunities aiming to better respond to the psychological health needs of this population.

To test whether there are gender differences in treatment outcomes among patients receiving injectable opioids for the treatment of long-term opioid-dependence. The study additionally explores whether men and women have different perceptions of treatment effectiveness. This study is a secondary analysis from SALOME, a double-blind, phase III, randomized controlled trial testing the non-inferiorirty of injectable hydromorphone to injectable diacetylmorphine among 202 long-term street opioid injectors in Vancouver (Canada). Given this was a secondary analysis, no a priori power calaculation was conducted. Differences in baseline characteristics and six-month treatment outcomes (illicit heroin use, opioid use, crack cocaine use, non-legal activities, physical and psychological health scores, urine positive for street heroin markers, and retention) were analysed by gender using fitted models. Responses to an open ended question on reasons for treatment effectiveness were explored with a thematic analysis. Men and women differed significantly on a number of characteristics at baseline. For example, women were significantly younger, presented to treatment with significantly higher rates of prior month sex work (31.5% vs. 0%), and used significantly more crack cocaine (14.71 vs. 8.38 days). After six-months of treatment there were no significant differences in treatment outcomes by gender, after adjusting for baseline values. For both men and women, improved health and quality of life were the most common reasons provided for treatment effectiveness, however women were more specific in the types of health improvements. Despite presenting to treatment with vulnerabilities not faced to the same extent by men, at six-months women did not differ significantly from men in tested trial efficacy outcomes. While the primary outcome in the trial was the reduction of illicit opioid use, in the open-ended responses both men and women focused their comments on improvement in health and quality of life as reasons for treatment effectiveness. The supervised model of care with injectable medications provides a particularly suitable framework for providing care to opioid-dependent men and women not attracted or retained by other treatments. The absence of statistical differences reported in this secondary analysis may be due to lack of adequate statistical power to detect meaningful effects. This trial is registered with ClinicalTrials.gov (NCT01447212) Registered: October 4, 2011 at the following link: https://clinicaltrials.gov/ct2/show/NCT01447212 .

Background Indigenous leaders continue to be concerned about high rates of HIV and barriers to HIV treatment among young Indigenous people involved in substance use. Growing evidence suggests that using mobile phones for health (mHealth) may be a powerful way to support connection with health services, including HIV prevention and treatment. Objective This study examined the patterns of mobile phone ownership and use among young Indigenous people who have used drugs living with or vulnerable to HIV and explored the acceptability of mHealth to support access to health care in this population. Methods The Cedar Project is a cohort study involving young Indigenous people who have used drugs in Vancouver and Prince George, British Columbia. This mixed methods exploratory study involved 131 Cedar Project participants enrolled in our WelTel mHealth program. At enrollment, participants completed a questionnaire related to mobile phone use and interest in mHealth. Data were linked to Cedar Project questionnaires and serodata. We present comparative statistics (quantitative) and results of a rapid thematic analysis (qualitative) related to mobile phone patterns and interest in receiving mHealth. Results Less than half of the participants (59/130; 45.4%) reported owning a phone. Among those with a phone, the majority owned a smartphone (46/59; 78%). Most participants with a phone reported having an unlimited texting plan (39/55; 71%), using the internet on their phone (44/59; 75%), and texting daily (44/55; 80%). A majority reported that using a mobile phone for health would be invaluable (120/130; 92.3%). There were no differences in mHealth acceptance between participants who owned a phone and those who did not (P>.99). All but one participant living with HIV felt using a mobile phone would be helpful for their health, while a small proportion of HIV-negative participants remained unsure (1.9% vs 11.7%; P=.047). In response to open-ended questions asking why using a mobile phone may be helpful for health, participants identified a diverse set of anticipated benefits: (1) connection for emotional, mental, and spiritual support, (2) connection to family, (3) staying in touch and/or being reachable, (4) overcoming current barriers to phone use, (5) convenience, privacy, and safety, and (6) access to health care and emergency services. Conclusions We observed high acceptance and interest in using mobile phone technology for health despite low rates of personal mobile phone connectivity among young Indigenous people who have used drugs living with and vulnerable to HIV in British Columbia, Canada. Mobile phones were viewed as a way to support connections and relationships that are seen as critical to health and well-being among young Indigenous people in this study. Findings may be useful for health care providers preparing to scale up mHealth programs to support HIV prevention and treatment in this population.

BackgroundDespite ongoing efforts aimed to improve treatment engagement for people with substance-related disorders, evidence shows modest rates of utilization as well as client-perceived barriers to care. Patient-centered care (PCC) is one widely recognized approach that has been recommended as an evidence-based practice to improve the quality of substance use disorder treatment. PCC includes four core principles: a holistic and individualized focus to care, shared decision-making and enhanced therapeutic alliance.AimsThis scoping review aimed to explore which PCC principles have been described and how they have defined and measured among people with substance-related disorders.MethodsFollowing the iterative stages of the Arksey and O’Malley scoping review methodology, empirical (from Medline, Embase, PsycINFO, CINAHL and ISI Web of Science) and grey literature references were eligible if they focused on people accessing treatment for substance-related disorders and described PCC. Two reviewers independently screened the title/abstract and full-texts of references. Descriptive analyses and a directed content analysis were performed on extracted data.FindingsOne-hundred and forty-nine references met inclusion from the 2951 de-duplicated references screened. Therapeutic alliance was the most frequent principle of PCC described by references (72%); this was consistently defined by characteristics of empathy and non-judgment. Shared decision-making was identified in 36% of references and was primarily defined by client and provider strategies of negotiation in the treatment planning process. Individualized care was described by 30% of references and included individualized assessment and treatment delivery efforts. Holistic care was identified in 23% of references; it included an integrated delivery of substance use, health and psychosocial services via comprehensive care settings or coordination. Substance use and treatment engagement outcomes were most frequently described, regardless of PCC principle.ConclusionsThis review represents a necessary first step to explore how PCC has been defined and measured for people accessing substance use disorder treatment. The directed content analysis revealed population and context-specific evidence regarding the defining characteristics of PCC-principles that can be used to further support the implementation of PCC.

Indigenous leaders remain concerned that systemic oppression and culturally unsafe care impede Indigenous peoples living with HIV from accessing health services that make up the HIV cascade of care. We conducted a systematic review to assess the evidence related to experiences of the HIV care cascade among Indigenous peoples in Australia, Canada, New Zealand, and United States. We identified 93 qualitative and quantitative articles published between 1996 and 2017 reporting primary data on cascade outcomes disaggregated by Indigenous identity. Twelve involved data from Australia, 52 from Canada, 3 from New Zealand and 26 from United States. The majority dealt with HIV testing/diagnosis (50). Relatively few addressed post-diagnosis experiences: linkage (14); retention (20); treatment initiation (21); adherence (23); and viral suppression (24). With the HIV cascade of care increasingly the focus of global, national, and local HIV agendas, it is critical that culturally-safe care for Indigenous peoples is available at all stages.

Background: SALOME (Study to Assess Longer-term Opioid Medication Effectiveness) tested in a double-blind non-inferiority clinical trial if hydromorphone could be as effective as diacetylmorphine for severe opioid use disorder. Although participants did not guess treatment correctly beyond what is expected by chance, perceived treatment assignment could affect patients’ response to treatment. This study tested if treatment allocation guess is associated with treatment outcomes and identified predictors of guess.Methods: Data were obtained through questionnaires and clinical records. Participants were asked what medication they thought they were receiving (diacetylmorphine, hydromorphone or unsure) and their open-ended reasons. Multinomial logistic regression was used to assess the predictors of treatment guess. An inductive thematic analysis was used to code open-ended responses. This clinical trial was registered with U.S. National Institutes of Health (https://clinicaltrials.gov/ct2/show/NCT0144...

IntroductionSubstance use disorders are chronic conditions that require a multidimensional treatment approach. Despite ongoing efforts to diversify such treatments, evidence continues to illuminate modest rates of treatment engagement and perceived barriers to treatment. Patient-centred care (PCC) is one approach that may strengthen the responsiveness of treatments for people with problematic substance use. The aim of this scoping review is to explore how the principles of PCC have been implemented and operationalised in healthcare settings for people with problematic substance use.Methods and analysisThis scoping review follows the iterative stages of the Arksey and O’Malley framework. Both empirical (from Medline, Embase, PsycINFO, CINAHL and ISI Web of Science) and grey literature references will be considered if they focused on populations with problematic substance use and described or measured PCC or one of its principles in a health-oriented context. Two reviewers will independently screen references in two successive stages of title/abstract screening and then full-text screening for references meeting title/abstract criteria. A descriptive overview, tabular and/or graphical summaries, and a directed content analysis will be carried out on extracted data. This scoping review has been registered with Open Science Framework (https://osf.io/5swvd/).Ethics and disseminationThis review will systematically examine the extent and nature of existing evidence of PCC in addiction research and clinical practice. Such evidence will contribute to the operationalisation of PCC for people with problematic substance use. A multidisciplinary team has been gathered to represent the needs of people with problematic substance use, healthcare providers and decision-makers. The team’s knowledge users will be engaged throughout this review and will participate in dissemination activities (eg, workshops, presentations, publications, reports).

Background In a double-blind, non-inferiority randomized controlled trial injectable hydromorphone, a licensed short acting opioid analgesic, was shown to be as effective as diacetylmorphine for the treatment of severe opioid use disorder. An appropriate question is whether hydromorphone offered open-label can attract and retain patients. Methods This is a retrospective study, using daily prescription data from the Crosstown Clinic in Vancouver, Canada. Treatment retention among participants who had the opportunity to receive open-label injectable hydromorphone for at least 90 consecutive days (n = 108) before having the choice of receiving open-label diacetylmorphine, was compared to their retention outcomes with double-blind injectable opioid agonist treatment (iOAT). McNemar tests analyzed differences in proportions; a conditional logistic model estimated exact odds ratios; Pairwise t-tests analyzed differences in total number of treatment days; and Kaplan-Meier curves and clustered log-rank tests compared time to first 30 continuous days without injectable treatment. Results A total of 74 participants (68.5%) were retained in both open-label hydromorphone and double-blind iOAT. Open-label hydromorphone was not significantly associated with lower retention (OR = 0.5; 95% CI: 0.2, 1.1; p = .10). Participants attended a mean of 84.4 (SD = 15.8) days of iOAT in the trial and 80.5 (SD = 22.0) days in open-label hydromorphone (mean difference of −3.9; 95% CI = −8.9, 1.1). Kaplan-Meier curves and log-rank tests were not statistically significant. Conclusion As treatment with injectable hydromorphone expands across Canada, our study contributes in a unique manner by providing evidence that the high retention rates observed during the clinical trial were maintained when participants started open-label hydromorphone.

Ethnic affiliation can define sociocultural boundaries and contribute to the HIV vulnerabilities faced by men who have sex with men (MSM). This study investigated the influence of ethnic affiliation on HIV vulnerabilities among MSM in North China. Our study analyzed a cross-sectional survey of MSM (n = 398) in two major North China cities. We examined associations between ethnic affiliation and (a) HIV status, (b) sexual behaviors and experiences, and (c) substance use. Compared to ethnic majority Han MSM: MSM belonging to ethnic minority groups of South China had significantly greater odds of HIV infection (AOR: 7.40; 95% CI: 2.33-23.47) and experience of forced sex (AOR: 3.27; 95% CI: 1.12-9.52). Compared to ethnic majority Han MSM, Ethnic Hui MSM had significantly lower odds of condomless anal sex (AOR: 0.41; 95% CI: 0.21-0.82) and significantly greater odds of circumcision (AOR: 2.62; 95% CI: 1.24-5.51). HIV prevalence and riskier sexual behaviors among MSM in China appear to vary significantly by ethnic affiliation. Current epidemiological practices of aggregating all ethnic minority groups in China into a single category may be masking important interethnic differences in HIV risk, and precluding opportunities for more culturally appropriate interventions.

Background.Mental health and wellbeing, including addressing impacts of historical trauma and substance use among young people, has been identified as a key priority by Indigenous communities and leaders across Canada and globally. Yet, research to understand mental health among young Indigenous people who have used drugs is limited.Aims.To examine longitudinal risk and strengths-based factors associated with psychological distress among young Indigenous people who use drugs.Method.The Cedar Project is an ongoing cohort study involving young Indigenous people who use drugs in Vancouver, Prince George, and Chase, British Columbia, Canada. This study included participants who completed the Symptom Checklist-90-Revised, returned for follow-up between 2010 and 2012, and completed the Childhood Trauma Questionnaire. Adjusted linear mixed-effects models estimated effects of study variables on changes in area T-scores of psychological distress.Results.Of 202 eligible participants, 53% were women and the mean age was 28 years. Among men, childhood maltreatment (emotional abuse, physical abuse, sexual abuse, physical neglect), any drug use, blackouts from drinking, and sex work were associated with increased distress. Among women, childhood maltreatment (emotional abuse, physical abuse, physical neglect), blackouts from drinking, and sexual assault were associated with increased distress, while having attempted to quit using drugs was associated with reduced distress. Marginal associations were observed between speaking their traditional language and living by traditional culture with lower distress among men.Conclusion.Culturally safe mental wellness interventions are urgently needed to address childhood trauma and harmful coping strategies that exacerbate distress among young Indigenous people who use drugs.

Aboriginal homelessness is considered to be a result of historic dispossession of traditional territories and forced displacement from community structures. Using data collected from 2005–2010 from the Cedar Project, a cohort of young Aboriginal people who use drugs in two Canadian cities, we examined how residential transience shapes HIV vulnerability. At baseline, 48 of 260 participants (18.5%) reported sleeping in six or more places (‘highly transient’) in the past six months. Generalized linear mixed models identified associations between high transience and sex and drug related HIV vulnerabilities. Transience was independently associated with sex work (AOR:3.52, 95%CI:2.06, 6.05); sexual assault (AOR:2.48, 95%CI:1.26, 4.86); injection drug use (AOR:4.54, 95%CI:2.71, 7.61); daily cocaine injection (AOR:2.16, 95%CI:1.26, 3.72); and public injection (AOR:2.87, 95%CI:1.65, 5.00). After stratification, transience and sexual vulnerability remained significantly associated among women but not men. Ensuring that young Aboriginal people have access to safe spaces to live, work, and inject must include policies addressing residential transience as well as the absence of a roof and walls.

This study explored trends of sexual assault and associated risk factors within a cohort of young Aboriginal women who used drugs in Vancouver and Prince George, Canada, between 2003 and 2010. Results demonstrated no change in the trend of sexual assault over time; however, odds of sexual assault were significantly higher for women who had at least one parent who attended residential school, had experienced childhood sexual abuse, were involved in sex work, had been offered money to not use condoms, had used injection drugs, had injected cocaine and opiates daily, had binged with injection drugs, and had difficulty accessing clean syringes. Findings highlight the urgency of interventions addressing the complexity of risk and opportunities for healing.

AimsTo investigate baseline and concurrent predictors of non-use of illicit heroin among participants randomized to injectable opioids in the North American Opiate Medication Initiative (NAOMI) clinical trial.MethodsNAOMI was an open-label randomized controlled trial comparing the effectiveness of injectable diacetylmorphine and hydromorphone for long-term opioid-dependency. Outcomes were assessed at baseline and during treatment (3, 6, 9, 12months). Days of non-use of illicit heroin in the prior month at each follow-up visit were divided into three categories: Non-use; Low use (1 to 7days) and High use (8days or more). Tested covariates were: Sociodemographics, Health, Treatment, Drug use and illegal activities. Mixed-effect proportional odds models with random intercept for longitudinal ordinal outcomes were used to assess the predictors of the non-use of illicit heroin.Results139 participants were included in the present analysis. At each follow-up visit, those with non-use of illicit heroin represented 47.5% to 54.0% of the sample. Fewer days of cocaine use (p=0.074), fewer days engaged in illegal activities at baseline (p

BACKGROUND: Young Indigenous people, particularly those involved in the child welfare system, those entrenched in substance use and those living with HIV or hepatitis C, are dying prematurely. We report mortality rates among young Indigenous people who use drugs in British Columbia and explore predictors of mortality over time. METHODS: We analyzed data collected every 6 months between 2003 and 2014 by the Cedar Project, a prospective cohort study involving young Indigenous people who use illicit drugs in Vancouver and Prince George, BC. We calculated age-standardized mortality ratios using Indigenous and Canadian reference populations. We identified predictors of mortality using time-dependent Cox proportional hazard regression. RESULTS: Among 610 participants, 40 died between 2003 and 2014, yielding a mortality rate of 670 per 100 000 person-years. Young Indigenous people who used drugs were 12.9 (95% confidence interval [CI] 9.2–17.5) times more likely to die than all Canadians the same age and were 7.8 (95% CI 5.6–10.6) times more likely to die than Indigenous people with Status in BC. Young women and those using drugs by injection were most affected. The leading causes of death were overdose (n = 15 [38%]), illness (n = 11 [28%]) and suicide (n = 5 [12%]). Predictors of mortality included having hepatitis C at baseline (adjusted hazard ratio [HR] 2.76, 95% CI 1.47–5.16), previous attempted suicide (adjusted HR 1.88, 95% CI 1.01–3.50) and recent overdose (adjusted HR 2.85, 95% CI 1.00–8.09). INTERPRETATION: Young Indigenous people using drugs in BC are dying at an alarming rate, particularly young women and those using injection drugs. These deaths likely reflect complex intersections of historical and present-day injustices, substance use and barriers to care.

Previous research has found diacetylmorphine, delivered under supervision, to be cost-effective in the treatment of severe opioid use disorder, but diacetylmorphine is not available in many settings. The Study to Assess Long-term Opioid Maintenance Effectiveness (SALOME) randomized controlled trial provided evidence that injectable hydromorphone is non-inferior to diacetylmorphine. The current study aimed to compare the cost-effectiveness of hydromorphone directly with diacetylmorphine and indirectly with methadone maintenance treatment.A within-trial analysis was conducted using the patient level data from the 6-month, double-blind, non-inferiority SALOME trial. A life-time analysis extrapolated costs and outcomes using a decision analytical cohort model. The model incorporated data from a previous trial to include an indirect comparison to methadone maintenance.A supervised clinic in Vancouver, British Columbia, Canada.A total of 202 long-term street opioid injectors who had at least two attempts at treatment, including one with methadone (or other substitution), were randomized to hydromorphone (n = 100) or diacetylmorphine (n = 102).We measured the utilization of drugs, visits to health professionals, hospitalizations, criminal activity, mortality and quality of life. This enabled us to estimate incremental costs, quality-adjusted life years (QALYs) and cost-effectiveness ratios from a societal perspective. Sensitivity analyses considered different sources of evidence, assumptions and perspectives.The within-trial analysis found hydromorphone provided similar QALYs to diacetylmorphine [0.377, 95% confidence interval (CI) = 0.361-0.393 versus 0.375, 95% CI = 0.357-0.391], but accumulated marginally greater costs [$49 830 ($28 401-73 637) versus $34 320 ($21 780-55 998)]. The life-time analysis suggested that both diacetylmorphine and hydromorphone provide more benefits than methadone [8.4 (7.4-9.5) and 8.3 (7.2-9.5) versus 7.4 (6.5-8.3) QALYs] at lower cost [$1.01 million ($0.6-1.59 million) and $1.02 million ($0.72-1.51 million) versus $1.15 million ($0.71-1.84 million)].In patients with severe opioid use disorder enrolled into the SALOME trial, injectable hydromorphone provided similar outcomes to injectable diacetylmorphine. Modelling outcomes during a patient's life-time suggested that injectable hydromorphone might provide greater benefit than methadone alone and may be cost-saving, with drug costs being offset by costs saved from reduced involvement in criminal activity.

Despite growing knowledge of the dynamics of HIV infection during conflict, far less is known about the period that follows cessation of hostilities and its implications for population health. This study sought to fill a lacuna in epidemiological evidence by examining HIV infection and related vulnerabilities of young people living in resource-scarce, post-emergency transit camps that are now home to thousands of displaced people following two decades of war in northern Uganda. In 2010, a cross-sectional demographic and behavioural survey was conducted with 384 transit camp residents aged 15-29 years old in Gulu District. Biological specimens were collected for rapid and confirmatory HIV testing. Separate multivariable logistic regression models by sex identified risk factors for HIV infection. HIV prevalence was 15.6% (95% confidence interval [CI]: 10.8%, 21.6%) among females and 9.9% (95% CI: 6.1%, 15.0%) among males. The strongest correlate of HIV infection among men was a non-consensual sexual debut (adjusted odds ratio [AOR] 3.24; 95% CI: 1.37-7.67), and having practiced dry sex (AOR 7.62; 95% CI: 1.56-16.95) was the strongest correlate among women. Conflict-affected men and women experience vulnerability to HIV infection in different ways than may have originally been understood. Post-conflict programme planners must therefore design and implement contextualised, evidence-based responses to HIV that are sensitive to gender and cultural issues.

Background context Waitlists are commonly used in Canada to manage access to surgical procedures such as elective surgical lumbar discectomy (ESLD). The timing of enrollment onto the waitlist is important as this is a proxy measure for the concordance of preferences for surgery between a patient and surgeon. After enrollment, the waiting time to actual surgery extends the duration of preoperative symptoms, which possibly affects the outcome of ESLD. Waiting time also specifically reflects the delay in service delivery imposed by the limited capacity of the health-care system. Purpose To determine if a system-imposed delay in treatment, that is, longer waiting time, for ESLD is associated with a higher odds of experiencing residual postoperative pain. Study design/setting Ambidirectional cohort study with 2-year retrospective and 3-year prospective components, conducted at a major tertiary care center serving a metropolitan area in Canada. Patient sample Patients aged 16 years or older with sciatica because of herniated lumbar disc, confirmed on advanced imaging, were recruited at the time of waitlist enrollment for ESLD. Patients with significant comorbidity or emergency indications for surgery were excluded. Of 391 participants, 291 had complete follow-up information at 6 months postoperatively. Outcome measure Intensity of the predominant symptom (worse of either back or leg pain) was assessed on the 11-point numerical rating scale at waitlist enrollment and 6 months postoperatively. Pain scores were highly skewed and therefore categorized into four ordinal levels defined by quartiles. Methods For the primary analysis, time to surgery from waitlist enrollment was dichotomized based on a predetermined clinically meaningful cut-point of 12 weeks. Ordinal logistic regression was used to compare the odds of experiencing higher pain intensity between wait groups. Control of confounders was achieved using both propensity scores and conventional multivariable modeling. Results In unadjusted analyses, long-wait patients were 80% more likely than short-wait patients to experience higher ordinal pain intensity at 6 months; unadjusted proportional odds ratio (POR)=1.8 (95% confidence interval [CI], 1.2–2.8). The association held after controlling for all imbalances in measured confounders, with long-wait patients still being 70% more likely to report worse pain; adjusted POR=1.7 (95% CI, 1.0–2.8). Conclusions A waiting time of 12 weeks or more after waitlist enrollment for ESLD is associated with a modest likelihood of experiencing worse pain at 6 months postoperatively. This result was not because of differences in measured confounders. Future studies are encouraged to identify other, as-of-yet unmeasured, variables that might be associated with both longer waiting times and worse outcomes among ESLD patients. Until then, in jurisdictions where highly constrained access to ESLD is managed through waitlists, the expected waiting time for the operation could be an informative deciding criterion for patients with otherwise unresolved preferences for operative treatment.

Little information exists on the use of condoms as protective barriers to sexually transmitted infections (STIs) among indigenous people in Canada. This study explores risk factors of inconsistent condom use (during consensual sex) over time among participants in the Cedar Project, a prospective cohort study of indigenous young people living in Vancouver and Prince George, British Columbia, who use drugs. Due to the serial measurements for each study subject, generalized estimating equations modeling with logit link was used to accommodate the temporal correlation within subjects. For young women, inconsistent condom use over time was predicted by having a recent STI (adjusted odds ratio [AOR] = 1.76, 95% confidence interval [CI] [1.12, 2.79]), smoking crack daily (AOR = 1.63, 95%CI [1.02, 2.61]), and having experienced recent sexual abuse (AOR = 2.07, 95%CI [1.20, 3.56]). Among young men, living in Prince George (AOR = 1.63, 95%CI [1.14, 2.39]) and daily crack smoking (AOR = 1.56, 95%CI [1.02, 2...

Background Policing has profound health implications for people who use illicit drugs. Among Aboriginal communities, distrust of police is common, due partly to legacies of colonial policing. In response to the paucity of research among Aboriginal people who use drugs, this paper aims to: (1) Describe the policing experiences of young Aboriginal people who use drugs; (2) Identify policing activities associated with unsafe injection practices; and (3) Elucidate barriers to positive police relations. Methods The Cedar Project is a cohort study involving young Aboriginal people in Vancouver and Prince George, British Columbia, who use illicit drugs. This mixed-methods study ( N =372) used period prevalence from 2007 to 2010 to describe policing experiences, mixed effects regression models to identify correlates of policing activities, and thematic qualitative analysis to assess attitudes to police relations. Results Many participants were stopped by police (73%), experienced physical force by police (28%), had drug equipment confiscated (31%), and changed location of drug use because of police (43%). Participants who reported dealing drugs (40%) were significantly more likely to experience police engagement. Among participants in Prince George, 4% reported to have had non-consensual sex with members of the criminal justice system. Policing activity was significantly associated with syringe sharing, rushed injection, and reused syringe. Due to personal experience, practical concerns, and intergenerational legacies of unfair policing practices, most participants did not want a positive relationship with police (57%). Desire for a positive relationship with police was directly associated with being helped by police, and inversely associated with being stopped by police and experiencing physical force by police. Conclusion Policing activities may be impacting the well-being of Aboriginal people who use drugs. Due to focused prosecution of street-level drug dealing, some police may favor enforcement over harm reduction. Positive police engagement and less aggressive policing may enhance perceptions of police among young Aboriginal people who use drugs.

Aims Despite increased use of the Alcohol Use Disorders Identification Test (AUDIT) in sub-Saharan Africa, few studies have assessed its underlying conceptual framework, and none have done so in post-conflict settings. Further, significant inconsistencies exist between definitions used for problematic consumption. Such is the case in Uganda, facing one of the highest per-capita alcohol consumption levels regionally, which is thought to be hindering rebuilding in the North after two decades of civil war. This study explores the impact of varying designation cutoff thresholds in the AUDIT as well as its conceptual factor structure in a representative sample of the population. Methods In all, 1720 Cango Lyec Project participants completed socio-economic and mental health questionnaires, provided blood samples and took the AUDIT. Participant characteristics and consumption designations were compared at AUDIT summary score thresholds of ≥3, ≥5 and ≥8. Confirmatory factor analyses (CFA) explored one-, two- and three-factor level models overall and by sex with relative and absolute fit indicators. Results There were no significant differences in participant demographic characteristics between thresholds. At higher cutoffs, the test increased in specificity to identify those with hazardous drinking, disordered drinking and suffering from alcohol-related harms. All conceptual models indicated good fit, with three-factor models superior overall and within both sexes. Conclusion In Northern Uganda, a three-factor AUDIT model best explores alcohol use in the population and is appropriate for use in both sexes. Lower cutoff thresholds are recommended to identify those with potentially disordered drinking to best plan effective interventions and treatments. Short summary A CFA of the AUDIT showed good fit for one-, two, and three-factor models overall and by sex in a representative sample in post-conflict Northern Uganda. A three-plus total AUDIT cutoff score is suggested to screen for hazardous drinking in this or similar populations.

To determine the effectiveness of injectable hydromorphone and dicaetylmorphine for Indigenous participants in the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) clinical trial. The study additionally aims to explore the prevalence and frequency of crack cocaine use among subgroups of participants (by gender and ethnicity). This secondary analysis is particularly relevant given the current need for expanded medication assisted treatments for opioid dependence across North America.Participants self-identifying as First Nations, Métis or Inuit were included in the analysis of Indigenous participants. Six-month treatment outcomes are reported as the difference between diacetylmorphine and hydromorphone treatment arms among Indigenous participants and change from baseline to 6 months in each treatment arm. Differences in outcomes are tested between Indigenous and non-Indigenous participants. Crack cocaine use was explored to determine differences between and within subgroups.Approximately one-third of SALOME participants self-identified as Indigenous. Indigenous participants presented to treatment with more structural vulnerabilities (e.g. lower education, higher rates of foster care and separation from biological parents) compared to non-Indigenous participants. After 6 months, Indigenous participants in both treatment arms had a significant reduction in days of street heroin use, opioid use, crack cocaine use and illegal activity. Treatment retention did not differ by treatment arm.Indigenous people that are not engaged by first-line treatments for opioid dependence are in need of effective alternative treatments. Given the political and logistical barriers facing diacetylmorphine, hydromorphone could serve as a more accessible medication to reach and treat this population. [Oviedo-Joekes E, Palis H, Guh D, Marchand K, Brissette S, Lock K, MacDonald S, Harrison S, Anis AH, Krausz M, March DC, Schechter MT. Characteristics and response to treatment among Indigenous people receiving injectable diacetylmorphine or hydromorphone in a randomised controlled trial for the treatment of long-termopioid dependence. Drug Alcohol Rev 2018;37:137-146].

Background The protracted war between the Government of Uganda and the Lord’s Resistance Army in Northern Uganda (1996–2006) resulted in widespread atrocities, destruction of health infrastructure and services, weakening the social and economic fabric of the affected populations, internal displacement and death. Despite grave concerns that increased spread of HIV/AIDS may be devastating to post conflict Northern Uganda, empirical epidemiological data describing the legacy of the war on HIV infection are scarce. Methods The ‘Cango Lyec’ Project is an open cohort study involving conflict-affected populations living in three districts of Gulu, Nwoya and Amuru in mid-northern Uganda. Between November 2011 and July 2012, 8 study communities randomly selected out of 32, were mapped and house-to-house census conducted to enumerate the entire community population. Consenting participants aged 13–49 years were enrolled and interviewer-administered data were collected on trauma, depression and socio-demographic-behavioural characteristics, in the local Luo language. Venous blood was taken for HIV and syphilis serology. Multivariable logistic regression was used to determine factors associated with HIV prevalence at baseline. Results A total of 2954 participants were eligible, of whom 2449 were enrolled. Among 2388 participants with known HIV status, HIV prevalence was 12.2% (95%CI: 10.8-13.8), higher in females (14.6%) than males (8.5%, p

BACKGROUND Religion can profoundly impact the sociocultural contexts that shape sexual HIV vulnerability among men who have sex with men (MSM). However, the relationship between religion and HIV vulnerability remains poorly understood for MSM in China, where religious affiliations and practices are rapidly increasing. METHODS Using cross-sectional survey data collected in Beijing and Tianjin, China, from 2013 to 2014 (n = 400), this study tests 3 hypotheses regarding religion and HIV sexual risk: (1) HIV vulnerabilities and testing patterns among religiously affiliated MSM are lower than for areligious MSM, (2) religiosity is inversely associated with HIV vulnerabilities and testing, and (3) the magnitude of inverse association between religiosity and HIV vulnerabilities/testing will be stronger among Christian and Muslim MSM than Buddhist and areligious MSM. RESULTS Compared with areligious participants, Buddhists had higher odds of reporting unprotected anal intercourse [adjusted odds ratio (AOR): 2.06, 95% confidence interval (CI): 1.13 to 3.75] and more male sex partners (AOR: 1.95, 1.16-3.27), whereas Muslims had lower odds of reporting unprotected anal intercourse (AOR: 0.33, 95% CI: 0.15 to 0.73) and higher odds of reporting male circumcision (AOR: 3.04, 95% CI: 1.45 to 6.40). Reporting of forced sex was associated with more frequent participation in social religious activities (AOR: 1.25, 95% CI: 1.02 to 1.52) and private religious activities (AOR: 1.30, 95% CI: 1.04 to 1.61). Among Christians, participation in private religious activities was associated with lower odds of reporting anal intercourse (AOR: 0.49, 95% CI: 0.27 to 0.88). CONCLUSIONS The sustained growth of multiple religious traditions in China appears to have important implications for HIV vulnerability among religious minority MSM.