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BackgroundIn British Columbia (BC), we are developing Get Checked Online (GCO), an Internet-based testing program that provides Web-based access to sexually transmitted infections (STI) testing. Much is still unknown about how to implement risk assessment and recommend tests in Web-based settings. Prediction tools have been shown to successfully increase efficiency and cost-effectiveness of STI case finding in the following settings. ObjectiveThis project was designed with three main objectives: (1) to derive a risk prediction rule for screening chlamydia and gonorrhea among clients attending two public sexual health clinics between 2000 and 2006 in Vancouver, BC, (2) to assess the temporal generalizability of the prediction rule among more recent visits in the Vancouver clinics (2007-2012), and (3) to assess the geographical generalizability of the rule in seven additional clinics in BC. MethodsThis study is a population-based, cross-sectional analysis of electronic records of visits collected at nine publicly funded STI clinics in BC between 2000 and 2012. We will derive a risk score from the multivariate logistic regression of clinic visit data between 2000 and 2006 at two clinics in Vancouver using newly diagnosed chlamydia and gonorrhea infections as the outcome. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow statistic will examine the model’s discrimination and calibration, respectively. We will also examine the sensitivity and proportion of patients that would need to be screened at different cutoffs of the risk score. Temporal and geographical validation will be assessed using patient visit data from more recent visits (2007-2012) at the Vancouver clinics and at clinics in the rest of BC, respectively. Statistical analyses will be performed using SAS, version 9.3. ResultsThis is an ongoing research project with initial results expected in 2014. ConclusionsThe results from this research will have important implications for scaling up of Internet-based testing in BC. If a prediction rule with good calibration, discrimination, and high sensitivity to detect infection is found during this project, the prediction rule could be programmed into GCO so that the program offers individualized testing recommendations to clients. Further, the prediction rule could be adapted into educational materials to inform other Web-based content by creating awareness about STI risk factors, which may stimulate health care seeking behavior among individuals accessing the website.

BackgroundInternet-based testing programs are being increasingly used to reduce testing barriers for individuals at higher risk of infection, yet the population impact and potential for exacerbation of existing health inequities of these programs are not well understood. ObjectiveWe used a large online sample of men who have sex with men (MSM) in Canada to measure acceptability of Internet-based testing and perceived advantages and disadvantages of this testing approach. MethodsWe asked participants of the 2011/2012 Sex Now Survey (a serial online survey of gay and bisexual men in Canada) whether they intended to use Internet-based testing and their perceived benefits and disadvantages of use. We examined whether intention to use was associated with explanatory variables spanning (A) sociodemographics, (B) Internet and technology usage, (C) sexually transmitted infections (STI)/ human immunodeficiency virus (HIV) and risk, and (D) health care access and testing, using multivariable logistic regression (variable selection using Bayesian information criterion). ResultsOverall, intention to use was high (5678/7938, 71.53%) among participants with little variation by participant characteristics. In our final model, we retained the variables related to (B) Internet and technology usage: use of Internet to cruise for sex partners (adjusted odds ratio [AOR] 1.46, 95% CI 1.25-1.70), use of Internet to search for sexual health information (AOR 1.36, 95% CI 1.23-1.51), and mobile phone usage (AOR 1.19, 95% 1.13-1.24). We also retained the variables for (D) health care access and testing: not “out” to primary care provider (AOR 1.24, 95% CI 1.10-1.41), delayed/avoided testing due to privacy concerns (AOR 1.77, 95% CI 1.49-2.11), and delayed/avoided testing due to access issues (AOR 1.65, 95% CI 1.40-1.95). Finally, we retained the variable being HIV positive (AOR 0.56, 95% CI 0.46-0.68) or HIV status unknown (AOR 0.89, 95% CI 0.77-1.01), age

BackgroundThe feasibility and acceptability of Internet-based sexually transmitted infection (STI) testing have been demonstrated; however, few programs have included testing for human immunodeficiency virus (HIV). In British Columbia, Canada, a new initiative will offer online access to chlamydia, gonorrhea, syphilis, and HIV testing, integrated with existing clinic-based services. We presented the model to gay men and other men who have sex with men (MSM) and existing clinic clients through a series of focus groups. ObjectiveTo identify perceived benefits, concerns, and expectations of a new model for Internet-based STI and HIV testing among potential end users. MethodsParticipants were recruited through email invitations, online classifieds, and flyers in STI clinics. A structured interview guide was used. Focus groups were audio recorded, and an observer took detailed field notes. Analysts then listened to audio recordings to validate field notes. Data were coded and analyzed using a scissor-and-sort technique. ResultsIn total, 39 people participated in six focus groups. Most were MSM, and all were active Internet users and experienced with STI/HIV testing. Perceived benefits of Internet-based STI testing included anonymity, convenience, and client-centered control. Salient concerns were reluctance to provide personal information online, distrust of security of data provided online, and the need for comprehensive pretest information and support for those receiving positive results, particularly for HIV. Suggestions emerged for mitigation of these concerns: provide up-front and detailed information about the model, ask only the minimal information required for testing, give positive results only by phone or in person, and ensure that those testing positive are referred for counseling and support. End users expected Internet testing to offer continuous online service delivery, from booking appointments, to transmitting information to the laboratory, to getting prescriptions. Most participants said they would use the service or recommend it to others. Those who indicated they would be unlikely to use it generally either lived near an STI clinic or routinely saw a family doctor with whom they were comfortable testing. Participants expected that the service would provide the greatest benefit to individuals who do not already have access to sensitive sexual health services, are reluctant to test due to stigma, or want to take immediate action (eg, because of a recent potential STI/HIV exposure). ConclusionsInternet-based STI/HIV testing has the potential to reduce barriers to testing, as a complement to existing clinic-based services. Trust in the new online service, however, is a prerequisite to client uptake and may be engendered by transparency of information about the model, and by accounting for concerns related to confidentiality, data usage, and provision of positive (especially HIV) results. Ongoing evaluation of this new model will be essential to its success and to the confidence of its users.

Suicide is a critical public health concern globally. Sex workers experience a disproportionate burden of social and health inequities driven by forms of violence, stigma, and criminalization, yet empirical research on suicidality is limited. This study longitudinally investigated the burden and socio-structural correlates of recent suicidality among women sex workers in Vancouver, Canada. Data (2010-2017) were drawn from a community-based, prospective cohort of cis and trans women sex workers across Metro Vancouver. Women completed biannual interviewer-administered questionnaires, and correlates of suicidality in the last 6 months were analyzed using bivariate and multivariable logistic regression with generalized estimating equations (GEE). Of 867 women at baseline, 48% (n = 413) reported lifetime suicidality, 16% (n = 141) reported suicidality in the last 6 months, and 29% reported suicidality at some point during the study. In multivariable analysis, factors independently associated with suicidality included physical/sexual childhood abuse (adjusted odds ratio [AOR]: 2.99; 95% confidence interval [CI] = [1.75, 5.10]), mental health issues (depression/anxiety/posttraumatic stress disorder; AOR = 2.19; 95% CI = [1.63, 2.95]), intimate partner violence (AOR: 2.11; 95% CI = [1.60, 2.80]), physical/sexual client violence (AOR: 1.82; 95% CI = [1.33, 2.50]), and homelessness (AOR: 1.44; 95% CI = [1.10, 1.89]). Older age (AOR: 0.97; 95% CI = [0.95, 0.99]) and higher social cohesion (AOR: 0.88; 95% CI = [0.78, 0.99]) were significantly associated with reduced odds of suicidality. Findings reveal key socio-structural correlates of suicidality among sex workers including experiences of historical and interpersonal violence, trauma/mental health issues, and homelessness. Strengthening social cohesion may have a protective effect on suicidality. Trauma-informed community-led structural interventions tailored to sex workers are urgently needed alongside a legal framework that enables collectivization and connectedness.

This study examines gradients in depressive symptoms by socioeconomic position (SEP; i.e., income, education, employment) in a sample of men who have sex with men (MSM). Data were used from EXPLORE, a randomized, controlled behavioral HIV prevention trial for HIV-uninfected MSM in six U.S. cities (n = 4,277). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression scale (short form). Multiple linear regressions were fitted with interaction terms to assess additive and multiplicative relationships between SEP and depressive symptoms. Depressive symptoms were more prevalent among MSM with lower income, lower educational attainment, and those in the unemployed/other employment category. Income, education, and employment made significant contributions in additive models after adjustment. The employment-income interaction was statistically significant, indicating a multiplicative effect. This study revealed gradients in depressive symptoms across SEP of MSM, pointing to income and employment status and, to a lesser extent, education as key factors for understanding heterogeneity of depressive symptoms.

BackgroundMigrant women in sex work experience unique risks and protective factors related to their sexual health. Given the dearth of knowledge in high-income countries, we explored factors associated with inconsistent condom use by clients among migrant female sex workers over time in Vancouver, BC.MethodsQuestionnaire and HIV/sexually transmitted infection testing data from a longitudinal cohort, An Evaluation of Sex Workers Health Access, were collected from 2010 to 2013. Logistic regression using generalized estimating equations was used to model correlates of inconsistent condom use by clients among international migrant sex workers over a 3-year study period.ResultsOf 685 participants, analyses were restricted to 182 (27%) international migrants who primarily originated from China. In multivariate generalized estimating equations analyses, difficulty accessing condoms (adjusted odds ratio [AOR], 3.76; 95% confidence interval [CI], 1.13-12.47) independently correlated with increased odds of inconsistent condom use by clients. Servicing clients in indoor sex work establishments (e.g., massage parlors) (AOR, 0.34; 95% CI, 0.15-0.77), and high school attainment (AOR, 0.22; 95% CI, 0.09-0.50) had independent protective effects on the odds of inconsistent condom use by clients.ConclusionsFindings of this longitudinal study highlight the persistent challenges faced by migrant sex workers in terms of accessing and using condoms. Migrant sex workers who experienced difficulty in accessing condoms were more than 3 times as likely to report inconsistent condom use by clients. Laws, policies, and programs promoting access to safer, decriminalized indoor work environments remain urgently needed to promote health, safety, and human rights for migrant workers in the sex industry.

BackgroundMethamphetamine (MA) use continues to be a major public health concern in many urban settings. We sought to assess potential relationships between MA use and individual, social, and structural HIV vulnerabilities among sexual minority (lesbian, gay, bisexual or transgendered) drug users.MethodsBeginning in 2005 and ending in 2008, 2109 drug users were enrolled into one of three cohort studies in Vancouver, Canada. We analysed longitudinal data from all self-identified sexual minority participants (n = 248). Logistic regression using generalized estimating equations (GEE) was used to examine the independent correlates of MA use over time. All analyses were stratified by biological sex at birth.ResultsAt baseline, 104 (7.5%) males and 144 (20.4%) females reported sexual minority status, among whom 64 (62.1%) and 58 (40.3%) reported MA use in the past six months, respectively. Compared to heterosexual participants, sexual minority males (odds ratio [OR] = 3.74, p < 0.001) and females (OR = 1.80, p = 0.003) were more likely to report recent MA use. In multivariate analysis, MA use among sexual minority males was associated with younger age (adjusted odds ratio [AOR] = 0.93 per year older, p = 0.011), Aboriginal ancestry (AOR = 2.59, p = 0.019), injection drug use (AOR = 3.98, p < 0.001), having a legal order or area restriction (i.e., "no-go zone") impact access to services or influence where drugs are used or purchased (AOR = 4.18, p = 0.008), unprotected intercourse (AOR = 1.62, p = 0.048), and increased depressive symptoms (AOR = 1.67, p = 0.044). Among females, MA use was associated with injection drug use (AOR = 2.49, p = 0.002), Downtown South residency (i.e., an area known for drug use) (AOR = 1.60, p = 0.047), and unprotected intercourse with sex trade clients (AOR = 2.62, p = 0.027).ConclusionsMethamphetamine use was more prevalent among sexual minority males and females and was associated with different sets of HIV risks and vulnerabilities. Our findings suggest that interventions addressing MA-related harms may need to be informed by more nuanced understandings of the intersection between drug use patterns, social and structural HIV vulnerabilities, and gender/sexual identities. In particular, MA-focused prevention and treatment programs tailored to disenfranchised male and female sexual minority youth are recommended.

Injection drug users (IDU) who use methamphetamine (MA) are at an increased risk of HIV infection due to engagement in injection-related risk behavior including syringe sharing. In this cohort study of young IDU aged 18-30, we investigated the relationship between injection MA use and syringe sharing, and whether difficulty accessing sterile syringes mediated this association. Behavioral questionnaires were completed by 384 IDU in Vancouver, Canada between October 2005 and May 2008. Generalized estimating equations were used to estimate direct and indirect effects. The median age of participants was 24 (IQR: 22-27) and 214 (55.7%) were male. Injecting MA was independently associated with syringe sharing. Mediation analyses revealed that difficulty accessing sterile syringes partially mediated the association between injecting MA and syringe sharing. Interventions to reduce syringe sharing among young methamphetamine injectors must address social and structural barriers to accessing HIV prevention programs.

Introduction: British Columbia has made significant progress in the treatment and prevention of HIV since 1996, when Highly Active Antiretroviral Therapy (HAART) became available. However, we currently lack a historical summary of HIV prevention and care interventions implemented in the province since the introduction of HAART and how they have shaped the HIV epidemic. Guided by a socio-ecological framework, we present a historical review of biomedical and health services, community and structural interventions implemented in British Columbia from 1996-2015 to prevent HIV transmission or otherwise enhance the cascade of HIV care. Methods: We constructed a historical timeline of HIV interventions implemented in BC between 1996 and 2015 by reviewing publicly available reports, guidelines and other documents from provincial health agencies, community organizations and AIDS service organizations, and by conducting searches of peer-reviewed literature through PubMed and Ovid MEDLINE. We collected further programmatic information by administering a data collection form to representatives from BC's regional health authorities and an umbrella agency representing 45 AIDS Service organizations. Using linked population-level health administrative data, we identified key phases of the HIV epidemic in British Columbia, as characterized by distinct changes in HIV incidence, HAART uptake and the provincial HIV response. Results and Discussion: In total, we identified 175 HIV prevention and care interventions implemented in BC from 1996 to 2015. We identify and describe four phases in BC's response to HIV/AIDS: the early HAART phase (1996-1999); the harm reduction and health service scale-up phase (2000-2005); the early Treatment as Prevention phase (2006-2009); and the STOP HIV/AIDS phase (2010-present). In doing so, we provide an overview of British Columbia's universal and centralized HIV treatment system and detail the role of community-based and provincial stakeholders in advancing innovative prevention and harm reduction approaches, as well as 'seek, test, treat and retain' strategies. Conclusions: The review provides valuable insight into British Columbia's HIV response, highlights emerging priorities, and may inform future efforts to evaluate the causal impact of interventions. Keywords: British Columbia; historical review; cascade of care; treatment as prevention; quality of care; harm reduction To access the supplementary material to this article please see Supplementary Files under Article Tools online., Introduction British Columbia (BC) has made substantial progress treating and preventing HIV since the infection emerged in the early 1980s. The introduction of highly active antiretroviral therapy (HAART) in 1996 [...]

Concepts of choice are often drawn upon within sexual health promotion discourses to encourage young people to take "responsibility" for and promote their own sexual health and reproductive control. A systematic literature search using predefined inclusion criteria identified peer-reviewed articles focusing on sexual health interventions for young people. Discourse analysis was used to interrogate how concepts of choice were articulated or inferred within the interventions. Of the eligible studies (n = 30), 16 were based on theories of behavioral change, suggesting a linear pathway between choice and improvements in sexual health. Studies that accounted for contextual factors were a minority (n = 6). Overall, study reports offered a limited account of the "situatedness" of young people's opportunities to exercise choice. This reliance had a tendency to position young people as passive recipients of interventions which seemed to undermine the more active notion of "making choices" presented within these frameworks.

Studies of parents' online safety concerns typically centre on information privacy and on worries over unknown third parties preying on children, whereas investigations into youth perspectives on online safety have found young people to focus on threats to safety or reputation by known individuals. The case of youth who are themselves parents raises questions regarding how these differing perspectives are negotiated by individuals who are in dual roles as youth and parents. Using interview and ethnographic observation data from the longitudinal Young Parent Study in British Columbia, Canada, this analysis investigates social media and online safety practices of 113 young parents. Online safety concerns of young parents in this study focused on personal safety, their children's online privacy and image management. These concerns reflect their dual roles, integrating youth image and information management concerns with parental concerns over the safety and information privacy of their own children. [ABSTRACT FROM AUTHOR]

Despite a general decline, early-age motherhood continues to manifest disproportionately among young women living in rural/remote Canada. Although public health interventions exist to ameliorate the negative impacts, key determinants of young mothers' well-being exist in sectors outside of health. Moreover, there is no clear understanding of how social context interacts with policy to enhance/detract from interventions. We undertook an ethnographic study in a northern Canadian city to investigate the impacts of sociocultural conditions and policy interventions on young mothers. "Ageing out" was identified as an important example of the intersection between social context and policy. "Ageing out" occurs when State-provided educational/income supports are removed because a young mother reaches the age of majority. Ageing out within unsupportive social contexts compounds negative consequences for young mothers, especially in relation to housing, parenting, and employment. The findings illustrate how some policy interventions have negative consequences that exacerbate health and social inequities. (Contains 1 note.)

Drawing on data from an ethnographic study examining the experiences of early-age mothers living in a remote city in northern British Columbia, Canada, we examine the perspectives of two study participants--one young mother and one service provider--who proposed that young mothers should visit high school classrooms to provide experiential narratives about the potential dangers of sex, particularly for young women. While many participants suggested that these peer-education presentations could be a positive experience for students as well as the young mothers/peer educators, the parables that their experiences represent reinforce social and physical distance between early-age mothers and mainstream society. Using a Foucauldian analysis, we demonstrate how these parables are more likely to demonize young women's sexualities and further alienate the young mothers from other teens.

This ethnographic study aimed at developing a richer understanding of how youth, their schools, and the communities in which they are emplaced coincide to generate a set of local social processes that affect marijuana use. We trace the interplay between high school staff and students with regards to marijuana use in the proximity of a local high school and the shifting geographies of use in this setting. Although marijuana use was a concern for teachers and administrators, they seemed unaware of how their strategies tended to reinforce use among teens. In and around the physical space of the school, social spaces for marijuana use were co-created by the actions of students and teachers. Groups of students would leave the school and smoke marijuana in school time. Students were aware that they needed to keep their use discrete. Teachers and staff unintentionally conveyed the message that marijuana use was acceptable provided it did not take place on school property. Students and staff thus enacted and reinforced the barriers to open communication about marijuana use. The teen appropriation of space to use marijuana can be interpreted as a counter-positioning of youth and adult norms. (Contains 1 figure and 2 notes.)

Most primary prevention research has attempted to explain sexual health outcomes, such as sexually transmitted infections, by focusing on individual characteristics (e.g. age), qualities (e.g. knowledge levels), and risk behaviour (e.g. unprotected intercourse). Emerging evidence indicates that population-level health outcomes are unlikely to be explained adequately as an aggregate of such individual-level factors. Rather, approaches that move beyond individualistic frameworks and adopt more ecological approaches may hold promise for promoting sexual health at the population level. This paper assessed the degree to which ecological approaches were integrated into empirical research regarding interventions to prevent sexually transmitted infections among adolescents. The paper also assessed the scientific rigour of the 35 intervention reports included in this review. Most (n = 31) reports focused exclusively on the micro-level (e.g. individual knowledge and attitudes) issues. No studies accounted for macro-level concerns (e.g. socio-cultural influences). Three reports were rated as methodologically "strong," 11 were of moderate quality and 21 reports were rated as "weak." Most sexual health interventions targeting adolescents have focused nearly exclusively on individual risk, but have failed to yield encouraging results in terms of behaviour change or reducing disease burden in this population. More attention should be paid to ecological approaches and new study methods should be explored. (Contains 2 tables and 3 notes.)