Research paperIncreasing awareness about HIV prevention among young people who initiated injection drug use in a Canadian setting, 1988–2014
Introduction
Injection drug use represents increased vulnerability to the human immunodeficiency virus (HIV) and remains a critical global issue. In 2013, there were an estimated 35 million people living with HIV globally. Outside of sub-Saharan Africa, 30% of new HIV infections were occurring amongst people who inject drugs (PWID), notably through the sharing of contaminated injection equipment (Joint United Nations Programme on HIV/AIDS, 2014b). It is also estimated that worldwide there are nearly 12.7 million PWID with roughly 1.7 million or 13% living with HIV (United Nations Office on Drugs and Crime, 2014). The prevalence of HIV amongst PWID remains almost 28 times as high as that in the general population (Joint United Nations Programme on HIV/AIDS, 2014a). Because HIV transmission through contaminated injection equipment is highly efficient, HIV can be rapidly spread in networks of PWID once introduced. For example, in the Middle East and Northern Africa, where HIV epidemics have primarily been driven by unprotected sexual behaviour, recent reviews have shown that injection drug use has recently emerged as a major driver of the epidemics (Joint United Nations Programme on HIV/AIDS, 2014b, Mumtaz et al., 2014). Thus, PWID continue to represent a key population for the global HIV/AIDS response.
Fortunately, over the past two decades, a number of evidence-based public health interventions have been developed in response to HIV transmission amongst PWID. These include needle and syringe programmes (NSPs) (Wodak and Cooney, 2006, World Health Organization, 2004b, World Health Organization et al., 2004), opioid agonist therapies (Mattick et al., 2009, World Health Organization, 2004a), and targeted education (Aggleton et al., 2005, Ball et al., 2005, Harm Reduction International, 2014); they have been endorsed by the United Nations agencies as key interventions to prevent HIV infection amongst PWID (United Nations Office on Drugs and Crime, Joint United Nations Programme on HIV/AIDS, 2012).
While a substantial amount of research has been done on the favourable impact of these public health interventions on HIV incidence amongst established PWID (Bastos and Strathdee, 2000, Des Jarlais et al., 2000, Des Jarlais, 2000a, Des Jarlais, 2000b, Monterroso et al., 2000, Vlahov et al., 2010), little is known about the effect of these interventions on young people who are initiating injection drug. This is a growing concern as a recent estimate of prevalence of HIV amongst young PWID under 25 years old was as high as 5.2% (Joint United Nations Programme on HIV/AIDS, 2014a). This indicates that there is a need to understand the awareness of young PWID regarding HIV risk behaviour and prevention at the onset of injection drug use.
Vancouver, Canada, experienced an explosive HIV outbreak amongst PWID in the mid-1990s, particularly in the city's Downtown Eastside neighbourhood, which houses close to one third of the PWID in Vancouver (Hyshka, Strathdee, Wood, & Kerr, 2012). This outbreak was characterized by some of North America's highest HIV incidence rates, despite the presence of public health efforts to prevent HIV implemented in this setting, including NSPs that were initiated in 1988 (Hyshka et al., 2012, Strathdee et al., 1997b). Accordingly, many questioned how this HIV outbreak could have occurred in the years following the initiation of NSPs (Wood et al., 2003, Wood et al., 2009). After extensive research, it became clear that Vancouver's PWID had a lot of difficulty in accessing sterile drug paraphernalia because of restrictive syringe exchange policies as well as programmatic barriers, such as limited NSP facilities and hours of operation (Hyshka et al., 2012, Strathdee et al., 1997b). Thus, even though NSPs were in place, they were not being optimally used by PWID. Fortunately, improvements were made to the NSPs in the early 2000s (Hyshka et al., 2012), which have led to declining rates of syringe sharing amongst PWID (Kerr et al., 2010). The existence of public health interventions that have been shown to reduce HIV risks among established PWID (Bastos and Strathdee, 2000, Monterroso et al., 2000, Wood et al., 2009) and the presence of large long-running prospective cohort studies of PWID beginning in 1996 in Vancouver make it an ideal setting to examine trends of awareness about HIV prevention and HIV risk behaviour amongst people who initiate injection drug use over a period of more than two decades. Our hypothesis for the present study was that PWID's awareness about HIV and NSPs at the time of first injection have risen with time, while rates of syringe borrowing (i.e., receptive syringe sharing) have decreased with time presumably because of the improvements in public health policy and NSPs in this setting.
Section snippets
Study design
Data for this analysis were derived from the assessments of a series of ongoing open prospective cohort studies involving people who use drugs, including the At-Risk Youth Study (ARYS), the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), and the Vancouver Injection Drug Users Study (VIDUS). The VIDUS study began enrolment in May 1996 and recruits individuals who injected drugs in the month prior to enrolment through word of mouth, street out-reach, and referrals. In 2005,
Summary statistics
In total, 1044 PWID were eligible for this analysis. The sample characteristics at the time of interview are described in Table 1 for the total sample and by individual cohorts. As shown, the median age at the time of interview was 28.7 years (interquartile range [IQR]: 22.8–37.6). Most participants were heterosexual male (58.7%), Caucasian (62.2%), received less than high school education (56.7%), and had experienced homelessness (91.2%). Two hundred and eighty-one (26.9%) were HIV-positive
Discussion
Among our sample of PWID in Vancouver who initiated injection drug use between 1988 and 2014, we found that awareness of HIV and NSPs at first injection has significantly increased over time after adjusting for socio-demographic characteristics. Similarly, rates of syringe borrowing at first injection have significantly decreased in bivariable analyses, although the declining rates were not determined to be significant in multivariable analyses.
Although the present study did not assess the
Acknowledgments
The authors thank the study participants for their contribution to the research, as well as current and past researchers and staff. The study was supported by the US National Institutes of Health (R01DA011591, U01DA038886, R01DA021525, R01DA028532) and the Canadian Institutes of Health Research (CIHR) (MOP-102742), and the Canadian Institutes of Health Research through the Canadian Research Initiative on Substance Misuse (FMN-139148). This research was undertaken, in part, thanks to funding
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