Street youth represent a marginalized population marked by early mortality and elevated risk for suicide. It is not known to what extent childhood abuse and neglect predispose to suicide in this difficult-to-study population. This study is among the first to examine the relationship between childhood trauma and subsequent attempted suicide during adolescence and young adulthood among street youth.
From October 2005 to November 2007, data were collected for the At Risk Youth Study (ARYS), a cohort of 495 street-recruited youth aged 14–26 in Vancouver, Canada. Self-reported attempted suicide in the preceding six months was examined in relation to childhood abuse and neglect, as measured by the Childhood Trauma Questionnaire (CTQ), using logistic regression.
Overall, 46 (9.3%) youth reported a suicide attempt during the preceding six months. Childhood physical and sexual abuse were highly prevalent, with 201 (40.6%) and 131 (26.5%) of youth reporting history of each, respectively. Increasing CTQ score was related to risk for suicide attempt despite adjustment for confounders (adjusted odds ratio [AOR], 1.45 per standard deviation increase in score; 95% confidence interval [CI], 1.08–1.91).
Use of snowball sampling may not have produced a truly random sample, and reliance on self-report may have resulted in underreporting of risk behaviors among participants. Moreover, use of cross-sectional data limits the degree to which temporality can be concluded from the results of this study alone.
There exists a strong and graded association between childhood trauma and subsequent attempted suicide among street youth, an otherwise ‘hidden’ population. There is need for effective interventions that not only prevent maltreatment of children but also aid youth at increased risk for suicide given prior history of trauma.
homeless youth; suicide; child abuse; child neglect; depression
Limited attention has been given to the potential role that the structure of housing available to people who are entrenched in street-based drug scenes may play in influencing the amount of time injection drug users (IDU) spend on public streets. We sought to examine the relationship between time spent socializing in Vancouver's drug scene and access to private space.
Using multivariate logistic regression we evaluated factors associated with socializing (three+ hours each day) in Vancouver's open drug scene among a prospective cohort of IDU. We also assessed attitudes towards relocating socializing activities if greater access to private indoor space was provided.
Among our sample of 1114 IDU, 43% fit our criteria for socializing in the open drug scene. In multivariate analysis, having limited access to private space was independently associated with socializing (adjusted odds ratio: 1.80, 95% confidence interval: 1.28 – 2.55). In further analysis, 65% of ‘socializers’ reported positive attitudes towards relocating socializing if they had greater access to private space.
These findings suggest that providing IDU with greater access to private indoor space may reduce one component of drug-related street disorder. Low-threshold supportive housing based on the ‘housing first’ model that include safeguards to manage behaviors associated with illicit drug use appear to offer important opportunities to create the types of private spaces that could support a reduction in street disorder.
injection drug use; street disorder; drug scenes; supportive housing; prospective cohort study
Despite the advent of effective antiretroviral therapy (ART), HIV-seropositive injection drug users (IDU) continue to suffer from elevated levels of morbidity and mortality. Evidence is needed to identify social- and structural-level barriers to effective ART. We investigated the impact of homelessness on plasma HIV RNA response among illicit drug users initiating ART in a setting with free and universal access to HIV care. We accessed data from a long-running prospective cohort of community-recruited IDU linked to comprehensive HIV clinical monitoring and ART dispensation records. Using Cox proportional hazards with recurrent events modeling, we estimated the independent effect of homelessness on time to plasma HIV viral load suppression. Between May 1996 and September 2009, 247 antiretroviral naïve individuals initiated ART and contributed 1755 person–years of follow-up. Among these individuals, the incidence density of plasma HIV RNA suppression less than 500 copies/mm3 was 56.7 (95% confidence interval [CI]: 46.9–66.0) per 100 person–years. In unadjusted analyses, homelessness was strongly associated with lower rates suppression (hazard ratio=0.56, 95% CI: 0.40–0.78, p=0.001), however, after adjustment for adherence this association was no longer significant (adjusted hazard ratio=0.79, 95% CI: 0.56–1.11, p=0.177). Homelessness poses a significant structural barrier to effective HIV treatment. However, since this relationship appears to be mediated by lower levels of ART adherence, interventions to improve adherence among members of this vulnerable population are needed.
Methamphetamine (MA) use is a growing public health concern in many settings around the world. While some physical and mental health effects associated with injection MA use have been well described, little is known about the relationship between injecting MA and suicidal behavior. We sought to determine whether MA injection was associated with an increased risk of attempting suicide among a prospective cohort of injection drug users (IDUs) in Vancouver, Canada.
Between 2001 and 2008, eligible participants enrolled in the Vancouver Injection Drug Users Study (VIDUS) completed semi-annual questionnaires that elicited information regarding sociodemographics, drug use patterns, and mental health problems including suicidal behavior. We used Cox proportional hazards models with time-dependent covariates to determine whether self-reported MA injection was an independent predictor of attempting suicide at subsequent time points.
Of 1873 eligible participants, 149 (8.0%) reported a suicide attempt, resulting in an incidence density of 2.51 per 100 person-years. Participants who attempted suicide were more likely to be younger (median: 35 vs. 40, p<0.01), female (48.3% vs. 35.1%, p<0.01), and of Aboriginal ancestry (43.6% vs. 31.3%, p<0.01). In a Cox proportional hazards model, MA injection was associated with an 80% increase in the risk of attempting suicide (adjusted hazard ratio = 1.80, 95%CI: 1.08 – 2.99, p=0.02).
These findings suggest that IDUs who inject MA should be monitored for suicidal behavior. Improved integration of mental health and suicide prevention interventions within harm reduction and drug treatment programs may be fruitful.
methamphetamine; suicide; injection; drug use; Canada; epidemiology
We aimed to characterize changes in patterns of new HIV diagnoses, HIV-related mortality, and HAART use in Canada from 1995 to 2008.
Data on new HIV diagnoses were obtained from Health Canada, HIV-related mortality statistics were obtained from Statistics Canada, and information on the number of people on HAART was obtained from the single antiretroviral distribution site in British Columbia (BC), and the Intercontinental Marketing Services Health for Ontario and Quebec. Trends of new HIV-positive tests were assessed using Spearman rank correlations and the association between the number of individuals on HAART and new HIV diagnoses were estimated using generalized estimating equations (GEE).
A total of 34,502 new HIV diagnoses were observed. Rates of death in BC are higher than those in Ontario and Quebec with the rate being 2.03 versus 1.06 and 1.21 per 100,000 population, respectively. The number of HIV infected individuals on HAART increased from 5,091 in 1996 to 20,481 in 2008 in the three provinces (4 fold increase). BC was the only province with a statistically significant decrease (trend test p<0.0001) in the rate of new HIV diagnoses from 18.05 to 7.94 new diagnoses per 100,000 population. Our analysis showed that for each 10% increment in HAART coverage the rate of new HIV diagnoses decreased by 8% (95% CI: 2.4%, 13.3%)
Except for British Columbia, the number of new HIV diagnoses per year has remained relatively stable across Canada over the study period. The decline in the rate of new HIV diagnoses per year may be in part attributed to the greater expansion of HAART coverage in this province.
Drug dealing among drug users has been associated with elevated risk-taking and negative health outcomes. However, little is known about the cessation of drug dealing among this population.
We assessed time to cessation of drug dealing using Cox regression. We also used generalized estimation equation (GEE) analysis and chi-square analysis to examine factors associated with willingness to cease drug dealing.
In total, 868 participants reported drug dealing between November 2005 and March 2009. Among 381 participants dealing drugs at baseline, 194 (51%) ceased dealing. Incidence of dealing cessation was positively associated with spending less than $50 per day on drugs (Adjusted Hazard Ratio [AHR] = 1.88, 95% Confidence Interval [CI]: 1.14 - 3.10) and negatively associated with buying drugs from the same source (AHR = 0.60, 95% CI: 0.37 - 0.98). In a GEE analysis, willingness to cease dealing was positively associated with older age (Adjusted Odds Ratio [AOR] = 1.02, 95% CI: 1.01 - 1.03), crack use (AOR = 2.00, 95% CI: 1.44 - 2.79), public injecting (AOR = 1.95, 95% CI: 1.55 - 2.43), and reporting that police presence affects drug purchases (AOR = 1.53, 95% CI: 1.22 - 1.91), and negatively associated with crystal methamphetamine injection (AOR = 0.62, 95% CI: 0.47 - 0.83).
Intensity of drug use and acquisition method were predictive of dealing cessation. Willingness to cease dealing was associated with a range of risky drug-related activities. Interventions to reduce drug dealing should be conceived in tandem with addiction treatment strategies.
drug dealing; crack use; crystal methamphetamine; drug markets; Vancouver
Income generation opportunities available to people who use illicit drugs have been associated with street disorder. Among a cohort of injection drug users (IDU) we sought to examine street-based income generation practices and willingness to forgo these sources of income if other low-threshold work opportunities were made available.
Data were derived from a prospective community recruited cohort of IDU. We assessed the prevalence of engaging in disorderly street-based income generation activities, including sex work, drug dealing, panhandling, and recycling/salvaging/vending. Using multivariate logistic regressions based on Akaike information criterion and the best subset selection procedure, we identified factors associated with disorderly income generation activities, and assessed willingness to forgo these sources of income during the period of November 2008 to July 2009.
Among our sample of 874 IDU, 418 (48%) reported engaging in a disorderly income generation activity in the previous six months. In multivariate analyses, engaging in disorderly income generation activities was independently associated with high intensity stimulant use, as well as binge drug use, having encounters with police, being a victim of violence, sharing used syringes, and injecting in public areas. Among those engaged in disorderly income generation, 198 (47%) reported a willingness to forgo these income sources if given opportunities for low-threshold employment, with sex workers being most willing to engage in alternative employment.
Engagement in disorderly street-based income generation activities was associated with high intensity stimulant drug use and various markers of risk. We found that a high proportion of illicit drug users were willing to cease engagement in these activities if they had options for causal low-threshold employment. These findings indicate that there is a high demand for low-threshold employment that may offer important opportunities to reduce drug-related street disorder and associated harms.
injection drug use; income generation; low-threshold employment; sex work; drug dealing; panhandling
Street-involved youth are an important population with respect to Hepatitis C. We therefore undertook this study to determine factors associated with HCV-antibody-positive status among street-involved youth. Vulnerabilities included injection drug use, ≥ 1 daily heroin and crystal methamphetamine injection. Implementing injection drug use prevention, evidence-based opioid substitution and crystal methamphetamine treatment programs for street-involved youth is critical.
We examined the impact of crystal methamphetamine injection on HIV RNA suppression among a prospective cohort of HIV-positive injection drug users initiating antiretroviral therapy. A multivariate Cox regression analysis found crystal methamphetamine injection to be negatively associated with viral load suppression (RH = 0.63 [95% CI: 0.40 – 0.98]; p = 0.039). This study is the first to our knowledge to demonstrate an association between crystal methamphetamine use and HIV RNA suppression.
methamphetamine; intravenous drug abuse; HIV; viral load
The psychosocial impacts of various types of childhood maltreatment on vulnerable illicit drug-using populations remains unclear. We examined the prevalence and correlates of antecedent emotional, physical and sexual abuse among a community-recruited cohort of adult HIV-seropositive illicit drug users.
We estimated the prevalence of childhood abuse at baseline using data from the Childhood Trauma Questionnaire, a 28-item validated instrument used to retrospectively assess childhood maltreatment. Logistic regression was used to estimate relationships between sub-types of childhood maltreatment with various social-demographic, drug-using and clinical characteristics.
Overall, 233 HIV-positive injection drug users (IDU) were included in the analysis, including 83 (35.6%) women. Of these, moderate or severe emotional childhood abuse was reported by 51.9% of participants; emotional neglect by 36.9%; physical abuse by 51.1%; physical neglect by 46.8%; and sexual abuse by 41.6%. In multivariate analyses, emotional, physical and sexual abuse were independently associated with greater odds of recent incarceration. Emotional abuse and neglect were independently associated with a score of ≥16 on the Centre for Epidemiologic Studies Depression Scale (CES-D). There was no association between any form of childhood maltreatment and clinical HIV variables, including viral load, CD4 count and history of antiretroviral therapy use.
These findings underscore the negative impact of childhood maltreatment on social functioning and mental health in later life. Given the substantial prevalence of childhood maltreatment among this population, there is a need for evidence-based resources to address the deleterious effect it has on the health and social functioning of HIV-positive IDU.
childhood trauma; drug users; HIV; social determinants of health
Rates of depression among street youth are poorly characterized, particularly as they pertain to concurrent drug use. We sought to assess associations between drug type and degree of depression in this population.
From October 2005 to November 2007, data were collected for the At-Risk Youth Study (ARYS), a cohort of street-recruited youth aged 14-26 in Vancouver, Canada. Active drug users were classified by predominant substance of use: daily marijuana use, weekly cocaine/crack use, weekly crystal methamphetamine use, or weekly heroin use. Adjusted mean number of depressive symptoms (measured by the Center for Epidemiological Studies Depression [CES-D] scale) was compared among the four groups using multiple linear regression. Logistic regression was also used to assess adjusted odds of CES-D score ≥22.
Among 447 youth, mean CES-D score was highest among heroin users (adjusted mean [SD], 22.7 [1.2]), followed by crystal methamphetamine users (21.8 [1.1]), then cocaine/crack users (19.1 [1.0]), and finally, marijuana users (18.3 [1.1]), a difference significant among groups (p < 0.001). When compared to daily marijuana users, odds of CES-D score ≥22 were higher among heroin users (adjusted odds ratio [AOR], 2.64; 95% confidence interval [CI], 1.39–4.99), and among crystal methamphetamine users (AOR, 1.88; 95% CI, 1.04–3.42) but not among cocaine/crack users (AOR, 1.41; 95% CI, 0.79–2.52).
To our knowledge, this is the first report of drug use typologies and depression among street youth. Policymakers might heed the apparent vulnerability of heroin and crystal methamphetamine users to even greater degrees of depression than their peers.
street youth; adolescents; injection; drug use; initiation
The purpose of this study was to determine the incidence and predictors of initiating methamphetamine injection among a cohort of injection drug users (IDU). We conducted a longitudinal analysis of IDU participating in a prospective study between June 2001 and May 2008 in Vancouver, Canada. IDU who had never reported injecting methamphetamine at the study's commencement were eligible. We used Cox proportional hazards models to identify the predictors of initiating methamphetamine injection. The outcome was time to first report of methamphetamine injection. Time-updated independent variables of interest included sociodemo-graphic characteristics, drug use patterns, and social, economic and environmental factors. Of 1317 eligible individuals, the median age was 39.9 and 522 (39.6%) were female. At the study's conclusion, 200 (15.2%) participants had initiated injecting methamphetamine (incidence density: 4.3 per 100 person-years). In multivariate analysis, age (adjusted hazard ratio [aHR]: 0.96 per year older, 95%CI: 0.95–0.98), female sex (aHR: 0.58, 95%CI: 0.41–0.82), sexual abuse (aHR: 1.63, 95% CI: 1.18–2.23), using drugs in Vancouver's drug scene epicentre (aHR: 2.15 95%CI: 1.49–3.10), homelessness (aHR: 1.43, 95%CI: 1.01–2.04), non-injection crack cocaine use (aHR: 2.06, 95%CI: 1.36–3.14), and non-injection methamphetamine use (aHR: 3.69, 95%CI: 2.03–6.70) were associated with initiating methamphetamine injection. We observed a high incidence of methamphetamine initiation, particularly among young IDU, stimulant users, homeless individuals, and those involved in the city's open drug scene. These data should be useful for the development of a broad set of interventions aimed at reducing initiation into methamphetamine injection among IDU.
Methamphetamine; Injection drug use; Risk behavior; Initiation; HIV
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.
injection drug use; antiretroviral therapy; syringe lending; HIV
(See the editorial commentary by Flanigan and Beckwith, on pages 1201–3.)
Background. Although some studies have identified impressive clinical gains for incarcerated HIV-seropositive injection drug users (IDUs) undergoing antiretroviral therapy (ART), the effect of incarceration on adherence to ART remains undetermined.
Methods. We used data from a long-term community-recruited cohort of HIV-seropositive IDUs, including comprehensive ART dispensation records, in a setting where HIV care is free. We estimated the relationship between the cumulative burden of incarceration, measured longitudinally, and the odds of <95% adherence to ART, with use of multivariate modeling.
Results. From 1996 through 2008, 490 IDUs were recruited and contributed 2220 person-years of follow-up; 271 participants (55.3%) experienced an incarceration episode, with the number of incarcerations totaling 1156. In a multivariate model, incarceration had a strong dose-dependent effect on the likelihood of nonadherence to ART: 1-2 incarceration events (adjusted odds ratio [AOR], 1.49; 95% confidence interval [95% CI], 1.03–2.05), 3–5 events (AOR, 2.48; 95% CI, 1.62–3.65), and > 5 events (AOR, 3.11; 95% CI, 1.86–4.95).
Conclusions. Among HIV-seropositive IDUs receiving ART, an increasing burden of incarceration was associated with poorer adherence in a dose-dependent fashion. Our findings support improved adherence support for HIV-seropositive IDUs experiencing incarceration.
Illegal drug use remains a serious threat to community health in Canada, yet there has been a remarkable discordance between scientific evidence and policy in this area, with most resources going to drug use prevention and drug law enforcement activities that have proven ineffective. Conversely, evidence-based drug treatment programs have been chronically underfunded, despite their cost-effectiveness. Similarly, various harm reduction strategies, such as needle exchange, supervised injecting programs and opioid substitution therapy, have also proven effective at reducing drug-related harm but receive limited government support. Accordingly, Canadian society would greatly benefit from reorienting its drug policies on addiction, with consideration of addiction as a health issue, rather than primarily a criminal justice issue. In this context, and in light of the simple reality that drug prohibition has not effectively reduced the availability of most illegal drugs and has instead contributed to a vast criminal enterprise and related violence, among other harms, alternatives should be prioritized for evaluation.
Regular HIV testing among people who inject drugs is an essential component of HIV prevention and treatment efforts. We explored HIV testing behaviour among a community-recruited sample of injection drug users (IDU) in Bangkok, Thailand.
Data collected through the Mitsampan Community Research Project were used to examine correlates of HIV testing behaviour among IDU and to explore reasons for not being tested. Multivariate logistic regression was used to examine factors associated with willingness to access HIV testing at the drug-user-run Mitsampan Harm Reduction Centre (MSHRC).
Among the 244 IDU who participated in this study, 186 (76.2%) reported receiving HIV testing in the previous six months. Enrolment in voluntary drug treatment (odds ratio [OR] = 2.34; 95% confidence interval [CI]: 1.18 - 4.63) and the tenofovir trial (OR = 44.81; 95%CI: 13.44 - 149.45) were positively associated with having been tested, whereas MSHRC use (OR = 1.78; 95%CI: 0.96 - 3.29) was marginally associated with having been tested. 56.9% of those who had not been tested reported in engaging in HIV risk behaviour in the past six months. 181 (74.2%) participants were willing to be tested at the MSHRC if testing were offered there. In multivariate analyses, willingness to get HIV testing at the MSHRC was positively associated with ever having been to the MSHRC (adjusted odds ratio [AOR] = 2.42; 95%CI: 1.21 - 4.85) and, among females, being enrolled in voluntary drug treatment services (AOR = 9.38; 95%CI: 1.14 - 76.98).
More than three-quarters of IDU received HIV testing in the previous six months. However, HIV risk behaviour was common among those who had not been tested. Additionally, 74.2% of participants were willing to receive HIV testing at the MSHRC. These findings provide evidence for ongoing HIV prevention education, as well potential benefits of incorporating HIV testing for IDU within peer-led harm reduction programs.
HIV testing; Injection drug use; Thailand; Peer-based interventions
Despite the availability of antiretroviral therapy (ART), suboptimal treatment outcomes have been observed among HIV-seropositive illicit drug users. As there is an urgent need to improve responses to antiretroviral therapy among this population, we undertook this study to evaluate the role of physician experience on rates of plasma HIV-1 RNA suppression following initiation of ART.
Using data from a community-recruited cohort of HIV-positive illicit drug users, we used Cox proportional hazards regression to model the time to plasma viral HIV RNA < 500 copies/mL among antiretroviral-naïve subjects initiating ART. Physician experience was defined as a continuous variable measured per 100 HIV-infected patients previously enrolled in the province-wide HIV treatment registry by that physician at the time a patient was enrolled.
Between May 1996 and December 2008, 267 individuals initiated ART among whom 227 (85%) achieved a plasma HIV RNA < 500 copies/mL during the study period. In a multivariate analysis, greater physician experience was independently associated with higher rates of plasma HIV RNA suppression (adjusted hazard ratio [AHR] = 1.17, 95% confidence interval [CI]: 1.03-1.34) after adjustment for adherence to ART. Other factors associated with viral suppression included engagement in methadone maintenance therapy (AHR = 1.61, 95% CI: 1.23-2.09), ≥ 95% adherence to ART (AHR = 2.42, 95% CI: 1.80-3.26), baseline CD4 count (AHR = 0.89, 95% CI: 0.83-0.96) and baseline plasma HIV-1 RNA (AHR = 0.65, 95% CI: 0.53-0.81).
In this setting of universal HIV/AIDS care, illicit drug users with more experienced physicians exhibited faster rates of plasma viral load suppression. These findings argue for specialized services to help optimize HIV treatment outcomes among this population.
Crack pipe sharing can increase health risks among people who use drugs, yet the reasons for sharing these pipes have not been well described. Therefore, we sought to identify the prevalence and correlates of crack pipe sharing among a community-recruited sample of people who use illicit drugs in Vancouver, a setting where crack pipes are provided at low or no cost.
Data for this study were derived from two prospective cohorts of people who use drugs: the Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS). Multivariate logistic regression was used to identify factors independently associated with crack pipe sharing. Among 503 crack users, 238 (47.3%) participants reported having shared a crack pipe in the previous six months. Having acquired a mouthpiece in the last six months (adjusted odds ratio [AOR] = 1.91; 95% confidence interval [CI]: 1.31 - 2.79) and difficulty finding new pipes (AOR = 2.19; 95%CI: 1.42 - 3.37) were positively associated with pipe sharing. Binge drug use (AOR = 1.39; 95%CI: 0.96 - 2.02) was marginally associated with sharing pipes.
There was a high prevalence of crack pipe sharing in a setting where crack pipes are distributed at low or no cost. Difficulty accessing crack pipes was independently and positively associated with this behavior. These findings suggest that additional efforts are needed to discourage crack pipe sharing as well as increase access to crack pipes.
crack cocaine smoking; injection drug use; harm reduction; sharing drug paraphernalia
Comprehensive HIV prevention interventions are increasingly recognized as critical in the global effort to reduce HIV transmission among people who use injection drugs (IDU). Scientific evidence clearly shows that a variety of biomedical, behavioral and structural interventions can prevent and reduce IDU-driven HIV epidemics, yet social and structural barriers to their implementation remain. This review discusses the scientific evidence on the effectiveness of individual programs for reducing HIV incidence among IDU and how, by integrating individual programs as complements within a comprehensive HIV prevention approach, it is possible to achieve, and to sustain, greater results than those of individual programs alone. The paper concludes with a discussion of a critical research priority; namely, to improve the implementation of comprehensive HIV prevention interventions in settings of prevalent injection drug use, and to overcome the often complex barriers that impede them. Such an effort will require more than research alone, however. It will also require the ongoing commitment of policy makers, public health officials, and the affected communities themselves to employ comprehensive HIV treatment and prevention as the most effective strategy to reduce new HIV infections.
HIV; injection drug use; intervention; prevention; review
Despite Thailand's official reclassification of drug users as "patients" deserving care and not "criminals," the Thai government has continued to rely heavily on punitive responses to drug use such as "boot camp"-style compulsory "treatment" centers. There is very little research on experiences with compulsory treatment centers among people who use drugs. The work reported here is a first step toward filling that gap.
We examined experiences of compulsory drug treatment among 252 Thai people who inject drugs (IDU) participating in the Mitsampan Community Research Project in Bangkok. Multivariate logistic regression was used to identify factors independently associated with a history of compulsory treatment experience.
In total, 80 (31.7%) participants reported a history of compulsory treatment. In multivariate analyses, compulsory drug detention experience was positively associated with current spending on drugs per day (adjusted odds ratio [AOR] = 1.86; 95%CI: 1.07 - 3.22) and reporting drug planting by police (AOR = 1.81; 95%CI: 1.04 - 3.15). Among those with compulsory treatment experience, 77 (96.3%) reported injecting in the past week, and no difference in intensity of drug use was observed between those with and without a history of compulsory detention.
These findings raise concerns about the current approach to compulsory drug detention in Thailand. Exposure to compulsory drug detention was associated with police abuse and high rates of relapse into drug use, although additional research is needed to determine the precise impact of exposure to this form of detention on future drug use. More broadly, compulsory "treatment" based on a penal approach is not consistent with scientific evidence on addressing drug addiction and should be phased out in favor of evidence-based interventions.
Compulsory treatment; Thailand; injection drug use
Although antiretroviral therapy (ART) dramatically reduces viral load and improves survival among HIV-infected injection drug users (IDU), several short-term studies have raised concerns that ART initiation may result in increases in sexual risk behaviour among IDU.
We used data from a long-running cohort of HIV-positive IDU to examine whether ART initiation was associated with increases in several measures of sexual risk behaviour. The date of ART initiation was determined through a validated linkage to a centralized ART dispensation pharmacy.
We used generalized linear mixed-effects modeling to examine whether sexual activity, unprotected intercourse, and multiple sexual partnerships were more likely in the 12 month period following ART initiation.
Among 457 individuals who were ART naïve at baseline, the median age was 34 (interquartile range [IQR]: 28–41) and 202 (44.2%) were female. Between May 1996 and April 2008, 260 (56.7%) participants initiated ART. In multivariate analyses, ART initiation was not associated with sexual activity (adjusted Odds Ratio [AOR] = 0.87, 95%CI: 0.60–1.25), unprotected intercourse (AOR = 0.82, 95%CI: 0.51–1.31), or multiple sexual partnerships (AOR = 0.93, 95%CI: 0.61–1.40).
In this study of HIV-positive IDU, we failed to detect an increase in sexual risk behaviour during the period following ART initiation. In light of this evidence, and given the known positive effect of ART on survival and its potential role in reducing HIV transmission, concerns regarding potential increases in sexual risk-taking should not undermine the delivery of ART to IDU.
injection drug use; antiretroviral therapy; sexual risk; HIV; AIDS
We examined methadone maintenance therapy (MMT) use among HIV-positive injection drug users (IDU) in Vancouver. Among 353 participants, 199 (56.3%) were on MMT at baseline, and 48 initiated MMT during follow-up. Female gender (adjusted odds ratio [AOR] = 1.73, 95% CI: 1.14 – 2.62) and antiretroviral therapy use (AOR = 2.04, 95% CI: 1.46 – 2.86) were positively associated with MMT use, while frequent heroin injection (AOR = 0.34, 95% CI: 0.23–0.50), public injection (AOR = 0.76, 95% CI: 0.59 – 0.97), syringe borrowing (AOR = 0.54, 95% CI: 0.32 – 0.90), and non-fatal overdose (AOR = 0.58, 95% CI: 0.36 – 0.92) were negatively associated with MMT use. The rate of discontinuation of MMT was 12.46 (95% CI: 8.28 – 18.00) per 100 person years. Frequent heroin use (adjusted hazards ratio = 4.49, 95%CI: 1.81 – 11.13) was positively associated with subsequent discontinuation of MMT. These findings demonstrate the benefits of MMT among HIV-positive IDU and the need to improve access to and retention in MMT.
methadone; injection drug use; HIV
Vancouver, Canada has been the site of an epidemic of human immunodeficiency virus (HIV) among injection drug users (IDU). In response, the Vancouver Area Network of Drug Users (VANDU) initiated a peer-run outreach-based syringe exchange programme (SEP) called the Alley Patrol. We conducted an external evaluation of this programme, using data obtained from the Vancouver Injection Drug Users Study (VIDUS).
Using generalised estimating equations (GEE) we examined the prevalence and correlates of use of the SEP among VIDUS participants followed from 1 December 2000 to 30 November 2003.
Of 854 IDU, 233 (27.3%) participants reported use of the SEP during the study period. In multivariate GEE analyses, service use was positively associated with living in unstable housing (Adjusted Odds Ratio [AOR] = 1.83, 95% Confidence Interval [CI]: 1.39 – 2.40), daily heroin injection (AOR = 1.31, 95% CI: 1.01 – 1.70), daily cocaine injection (AOR = 1.34, 95% CI: 1.03 – 1.73), injecting in public (AOR = 3.07, 95% CI: 2.32 – 4.06), and negatively associated with needle reuse (AOR = 0.65, 95% CI: 0.46 – 0.92).
The VANDU Alley Patrol SEP succeeded in reaching a group of IDU at heightened risk for adverse health outcomes. Importantly, access to this service was associated with lower levels of needle reuse. This form of peer-based SEP may extend the reach of HIV prevention programmes by contacting IDU traditionally underserved by conventional syringe exchange programmes.
injection drug use; syringe exchange; harm reduction; peer-driven approach; Vancouver
We compared drug-related behaviors, including initiation of drug use, among street youth residing in two adjacent neighborhoods in Vancouver. One neighborhood, the Downtown Eastside (DTES), features a large open-air illicit drug market.
In multivariate analysis, having a primary illicit income source (Adjusted Odds Ratio [AOR] = 2.64, 95% Confidence Interval [CI]: 1.16 – 6.02) and recent injection heroin use (AOR = 4.25, 95% CI: 1.26 – 14.29) were positively associated with DTES residence, while recent non-injection crystal methamphetamine use (AOR: 0.39, 95% CI: 0.16 – 0.94) was negatively associated with DTES residence. In univariate analysis, dealing drugs (Odds Ratio [OR] = 5.43, 95% CI: 1.24 – 23.82) was positively associated with initiating methamphetamine use in the DTS compared to the DTES.
These results demonstrate the importance of considering neighborhood variation when developing interventions aimed at reducing drug related harms among street-involved youth at various levels of street entrenchment.
street youth; crystal methamphetamine; initiation; injection drug use; drug dealing
Drug users engaged in survival sex work are at heightened risk for drug- and sexual-related harms. We examined factors associated with survival sex work among street-involved youth in Vancouver, Canada.
From September 2005 to November 2007, baseline data were collected for the At-Risk Youth Study (ARYS), a prospective cohort of street-recruited youth aged 14–26 who use illicit drugs. Using multiple logistic regression, we compared youth who reported exchanging sex for money, drugs etc. with those who did not.
The sample included 560 youth: median age 22; 179 (32%) female; 63 (11%) reporting recent survival sex work. Factors associated with survival sex work in multivariate analyses included non-injection crack use [adjusted odds ratio (AOR) = 3.45, 95% confidence interval (CI): 1.75–6.78], female gender (AOR = 3.02, 95% CI: 1.66–5.46), Aboriginal ethnicity (AOR = 2.35, 95% CI: 1.28–4.29) and crystal methamphetamine use (AOR = 2.02, 95% CI: 1.13–3.62). In subanalyses, the co-use of crack cocaine and methamphetamine was shown to be driving the association between methamphetamine and survival sex work.
This study demonstrates a positive interactive effect of dual stimulant use in elevating the odds of survival sex work among street youth who use drugs. Novel approaches to reduce the harms associated with survival sex work among street youth who use stimulants are needed.
Canada; prostitution; street youth; survival sex work