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1.  Does Initiation of HIV Antiretroviral Therapy Influence Patterns of Syringe Lending Among Injection Drug Users? 
Addictive behaviors  2011;36(5):560-563.
The delivery of antiretroviral therapy (ART) to injection drug users (IDU) may be influenced by provider concerns regarding the potential for increased HIV-related risk behavior following the initiation of HIV treatment. We evaluated whether ART initiation was associated with changes in syringe lending patterns among a long-term prospective cohort of HIV-positive IDU in Vancouver, Canada. Among 380 ART-naïve individuals eligible for this analysis, the median age was 34.2 (interquartile range [IQR] 27.7 – 40.8), 171 (45.0%) were female, and the median follow-up duration was 60 months (IQR = 18 – 113). Between May 1996 and April 2008, 260 (68.4%) participants initiated ART. In a generalized linear mixed-effects model which compared each individual’s likelihood of sharing syringes prior to and following the initiation of ART, syringe lending was not significantly associated with ART initiation in unadjusted (odds ratio = 0.72, 95% CI: 0.38 – 1.36) or adjusted (odds ratio = 0.78, 95% CI: 0.42 – 1.45) analyses. Concerns regarding increased injection risk behaviors following the initiation of ART were not observed in this setting.
doi:10.1016/j.addbeh.2011.01.022
PMCID: PMC3053580  PMID: 21320757
injection drug use; antiretroviral therapy; syringe lending; HIV
2.  The prevalence and incidence of sexually transmitted infections in a prospective cohort of injection drug users in Vancouver, British Columbia 
BACKGROUND:
While several studies have reported on sexual risk behaviours and the prevalence of sexually transmitted infections (STIs) among injection drug users (IDUs), there are fewer prospective studies that have been able to examine populations of IDUs with no history of STIs. Therefore, the authors examined prevalence, correlates and factors associated with time to first STI infection in a prospective cohort of IDUs in Vancouver, British Columbia.
METHODS:
The authors examined the prevalence and correlates of STIs among IDUs at the time of recruitment into a prospective cohort study. The authors also evaluated the cumulative rate of time to first STI among IDUs with no history of STIs at baseline using the Kaplan-Meier method, and modelled factors independently associated with first STI using Cox regression.
RESULTS:
Between May 1996 and November 2003, 1560 individuals were recruited into the cohort; of these individuals, 745 reported a history of STI at baseline. Among the 815 who did not report an STI at baseline, 671 (82%) had at least one follow-up visit and were eligible for the analysis of time to first STI. After 36 months of follow-up, the cumulative rate of first STI was 8.2% for men and 15.9% for women (log-rank P<0.001), whereas the cumulative rate of first STI was 8.0% for IDUs who did not report sex trade involvement versus 19.8% for IDUs who reported sex trade involvement (log-rank P<0.001). In multivariate analyses, the risk of first STI remained independently associated with unprotected sex with regular partners (relative hazard=2.04, 95% CI 1.29 to 3.23; P=0.001) and unprotected sex with sex trade clients (relative hazard=2.36, 95% CI 1.46 to 3.82; P=0.005).
CONCLUSIONS:
In the present study, the authors found that STIs were associated with both regular sex partnerships and sex trade involvement. These findings are of particular concern because both unprotected sex with regular partners and sex trade involvement is common among IDUs. Interventions to encourage condom use among IDUs, particularly those with regular sex partners and those involved in the sex trade, should be further developed.
PMCID: PMC2095031  PMID: 18159549
IDU; Prospective cohort; STI
3.  Potential uptake and correlates of willingness to use a supervised smoking facility for noninjection illicit drug use 
Many cities are experiencing infectious disease epidemics and substantial community harms as a result of illicit drug use. Although medically supervised smoking facilities (SSFs) remain untested in North America, local health officials in Vancouver are considering to prepare a submission to Health Canada for an exemption to open Canada’s first SSF for evaluation. Reluctance of health policymakers to initiate a pilot study of SSFs may be due in part to outstanding questions regarding the potential uptake and community impacts of the intervention. This study was conducted to evaluate the prevalence and correlates of willingness to use an SSF among illicit drug smokers who are enrolled in the Vancouver Injection Drug Users Study. Participants who reported actively smoking cocaine, heroin, or methamphetamine who returned for follow-up between June 2002 and December 2002 were eligible for these analyses. Those who reported willingness to use an SSF were compared with those who were unwilling to use an SSF by using logistic regression analyses. Four hundred and forty-three participants were eligible for this study. Among respondents, 124 (27,99%) expressed willingness to attend an SSF. Variables that were independently associated with willingness to attend an SSF in multivariate analyses included sex-trade work (adjusted odds ratio [AOR]=1.85), crack pipe sharing (AOR=2.24), and residing in the city’s HIV epicentre (AOR=1.64). We found that participants who demonstrated a willingness to attend an SSF were more likely to be involved in the sex trade and share crack pipes. Although the impact of SSFs in North America can only be quantified by scientific evaluation, these data indicate a potential for public health and community benefits if SSFs were to become available.
doi:10.1093/jurban/jti051
PMCID: PMC3456572  PMID: 15872188
Harm reduction; HCV; HIV; Supervised smoking facilitics
4.  The cost of inaction on HIV transmission among injection drug users and the potential for effective interventions 
Estimated and potential medical costs of treating patients infected with human immunodeficiency virus (HIV) in urban areas of high HIV prevalence have not been well defined. We estimated the total medical cost of HIV disease among injection drug users in Vancouver, British Columbia, Canada, assuming stable and increasing HIV prevalence. Total medical costs were estimated by multiplying the average lifetime medical cost per person by the number of HIV-infected individuals. We assumed the cost of each HIV infection to be $150,000 (Canadian), based on empirical data, and HIV prevalence estimates were derived from the Vancouver Injection Drug Users Study (VIDUS) and external data sources. By use of Monte Carlo simulation methodology, we performed sensitivity analyses to estimate total medical cost, assuming the HIV prevalence remained stable at 31% and under a scenario in which the prevalence rose to 50%. Expected medical expenditures based on current HIV prevalence levels were estimated as $215,852,613. If prevalence rises to 50% as reported in other urban centers, the median estimated medical cost would be approximately $348,935,865. This represents a difference in the total costs between the two scenarios of $133,083,253. Health planners should consider that predicted medical expenditures related to the HIV epidemic among injection drug users in our setting may cost an estimated $215,852,613. If funding cannot be found for appropriate prevention interventions and the prevalence rises to 50%, a further $133,083,253 may be required.
doi:10.1093/jurban/jth148
PMCID: PMC3455935  PMID: 15466846
AIDS; Cost; Health care; HIV; Injection drug use
5.  Predictors of Early Hospital Readmission in HIV-infected Patients with Pneumonia 
OBJECTIVE
Although hospitalization patterns have been studied, little is known about hospital readmission among HIV-infected patients in the era of highly active antiretroviral therapy. We explored the risk factors for early readmission to a tertiary care inner-city hospital among HIV-infected patients with pneumonia in Vancouver, Canada.
DESIGN
Case-control study.
SETTING
Tertiary care, university-affiliated, inner-city hospital.
PARTICIPANTS
All HIV-infected patients who were hospitalized with Pneumocystis carinii pneumonia (PCP) or bacterial pneumonia (BP) between January 1997 and December 2000. Case patients included those who had early readmissions, defined as being readmitted within 2 weeks of discharge (N = 131). Control patients were randomly selected HIV-infected patients admitted during the study period who were not readmitted within 2 weeks of discharge (N = 131), matched to the cases by proportion of PCP to BP.
MEASUREMENTS
Sociodemographic, HIV risk category, and clinical data were compared using χ2 test for categorical variables, and the Wilcoxon rank-sum test was used for continuous variables. Multivariable logistic regression was performed to determine the factors independently associated with early readmission. We also reviewed the medical records of 132 patients admitted to the HIV/AIDS ward during the study period and collected more detailed clinical data for a subanalysis.
MAIN RESULTS
Patients were at significantly increased odds of early readmission if they left the hospital against medical advice (AMA) (adjusted odds ratio [OR], 4.26; 95% confidence interval [95% CI], 2.13 to 8.55), lived in the poorest urban neighborhood (OR, 2.03; 95% CI, 1.09 to 3.77), were hospitalized in summer season (May though October, OR, 2.36; 95% CI, 1.36 to 4.10), or had been admitted in the preceding 6 months (OR, 2.55; 95% CI, 1.46 to 4.47). Gender, age, history of AIDS-defining illness, and injection drug use status were not significantly associated with early readmission.
CONCLUSIONS
Predictors of early readmission of HIV-infected patients with pneumonia included: leaving hospital AMA, living in the poorest urban neighborhood, being hospitalized in the preceding 6 months and during the summer months. Interventions involving social work may address some of the underlying reasons why these patients leave hospital AMA and should be further studied.
doi:10.1046/j.1525-1497.2003.20720.x
PMCID: PMC1494845  PMID: 12709090
case-control; hospital readmission; HIV; AIDS; bacterial pneumonia; PCP; antiretroviral therapy

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