Universal Coverage without Universal Access: Institutional Barriers to Health Care among Women Sex Workers in Vancouver, Canada

Background

Access to health care is a crucial determinant of health. Yet, even within settings that purport to provide universal health coverage (UHC), sex workers’ experiences reveal systematic, institutionally ingrained barriers to appropriate quality health care. The aim of this study was to assess prevalence and correlates of institutional barriers to care among sex workers in a setting with UHC.

Methods

Data was drawn from an ongoing community-based, prospective cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers’ Health Access). Multivariable logistic regression analyses, using generalized estimating equations (GEE), were employed to longitudinally investigate correlates of institutional barriers to care over a 44-month follow-up period (January 2010-August 2013).

Results

In total, 723 sex workers were included, contributing to 2506 observations. Over the study period, 509 (70.4%) women reported one or more institutional barriers to care. The most commonly reported institutional barriers to care were long wait times (54.6%), limited hours of operation (36.5%), and perceived disrespect by health care providers (26.1%). In multivariable GEE analyses, recent partner- (adjusted odds ratio [AOR] = 1.46, % 95% Confidence Interval [CI] 1.10–1.94), workplace- (AOR = 1.31, 95% CI 1.05–1.63), and community-level violence (AOR = 1.41, 95% CI 1.04–1.92), as well as other markers of vulnerability, such as self-identification as a gender/sexual minority (AOR = 1.32, 95% CI 1.03–1.69), a mental illness diagnosis (AOR = 1.66, 95% CI 1.34–2.06), and lack of provincial health insurance card (AOR = 3.47, 95% CI 1.59–7.57) emerged as independent correlates of institutional barriers to health services.

Discussion

Despite Canada’s UHC, women sex workers in Vancouver face high prevalence of institutional barriers to care, with highest burden among most marginalized women. These findings underscore the need to explore new models of care, alongside broader policy changes to fulfill sex workers’ health and human rights.

Below: Frequency of institutional-level barriers to health care among sex workers in Vancouver, Canada, 2010–2013

Full article at:   http://goo.gl/2p7VoO

By: 

M. Eugenia Socías, Paul Nguyen, Julio Montaner, Kate Shannon 
British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada

M. Eugenia Socías, Julio Montaner, Kate Shannon 

Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC, Canada

Jean Shoveller 

School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada

Chili Bean

Sex Workers United Against Violence Society, Vancouver, BC, Canada

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Injecting drugs in tight spaces: HIV, cocaine and collinearity in the Downtown Eastside, Vancouver, Canada

This commentary revisits the political turmoil and scientific controversy over epidemiological study findings linking high HIV seroincidence to syringe exchange attendance in Vancouver in the mid-1990s. The association was mobilized polemically by US politicians and hard-line drug warriors to attack needle exchange policies and funding. In turn, program restrictions limiting access to syringes at the Vancouver exchange may have interfaced with a complex conjunction of historical, geographic, political economic and cultural forces and physiological vulnerabilities to create an extraordinary HIV risk environment: 

1. ghettoization of services for indigent populations in a rapidly gentrifying, post-industrial city; 
2. rural-urban migration of vulnerable populations subject to historical colonization and current patterns of racism; and 
3. the flooding of North America with inexpensive powder cocaine and heroin, and the popularity of crack. 

In fact, we will never know with certainty the precise cause for the extreme seroincidence rates in Vancouver in the early to mid-1990s. 

The tendency for modern social epidemiology to decontextualize research subjects and assign excessive importance to discrete, "magic bullet" variables resulted in a counterproductive scientific and political debate in the late 1990s that has obfuscated potentially useful practical lessons for organizing the logistics of harm reduction services - especially syringe exchange - to better serve the needs of vulnerable populations and to mitigate the effects of political-economically imposed HIV risk environments. 

We would benefit from humbly acknowledging the limits of public health science and learn to recognize the unintended consequences of well-intentioned interventions rather than sweep embarrassing histories under the rug.

Purchase full article at:   http://goo.gl/FubNuW

By:  Ciccarone D¹, Bourgois P².

¹Family and Community Medicine, UCSF 500 Parnassus Avenue, MU-3E, Box 0900, San Francisco, CA 94143-0900, United States. Electronic address: Daniel.Ciccarone@ucsf.edu.

²Psychiatry, Center for Social Medicine, UCLA, 760 Westwood Plaza, B7-435, Los Angeles, CA 90025, United States.

Int J Drug Policy. 2016 Mar 8. pii: S0955-3959(16)30060-3. doi: 10.1016/j.drugpo.2016.02.028.

  

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No association between HIV status and risk of non-fatal overdose among people who inject drugs in Vancouver, Canada

BACKGROUND:

The evidence to date on whether HIV infection increases the risk of accidental drug overdose among people who inject drugs (PWID) is equivocal. Thus, we sought to estimate the effect of HIV infection on risk of non-fatal overdose among two parallel cohorts of HIV-positive and -negative PWID.

METHODS:

Data were collected from a prospective cohort of PWID in Vancouver, Canada between 2006 and 2013. During biannual follow-up assessments, non-fatal overdose within the previous 6months was assessed. Bivariable and multivariable generalized mixed-effects regression models were used to determine the unadjusted and adjusted associations between HIV status, plasma HIV-1 RNA viral load, and likelihood of non-fatal overdose.

RESULTS:

A total of 1760 eligible participants (67% male, median age=42, and 42% HIV-positive at baseline) were included. Among 15,070 unique observations, 649 (4.3%) included a report of a non-fatal overdose within the previous 6months (4.4% among seropositive and 4.3% among seronegative individuals). We did not observe a difference in the likelihood of overdose by HIV serostatus in crude (odds ratio [OR]: 1.05, p=0.853) analyses or analyses adjusted for known overdose risk factors (adjusted OR [AOR]: 1.19, p=0.474). In a secondary analysis, among HIV-positive PWID, we did not observe an association between having a detectable viral load and overdose (AOR: 1.03, p=0.862).

CONCLUSIONS:

Despite the evidence that HIV infection is a risk factor for fatal overdose, we found no evidence for a relationship between HIV disease and non-fatal overdose. However, overdose remains high among PWID, indicating the need for ongoing policy addressing this problem, and research into understanding modifiable risk factors that predict non-fatal overdose.

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By:  Escudero DJ1, Marshall BD1, Kerr T2, Hayashi K2, Feng C3, Guillemi SA3, Hogg RS3, Montaner J2, Wood E2, Milloy MJ4.

• 1Department of Epidemiology, Brown University School of Public Health, 2nd Floor, 121 S. Main St., Providence, RI 02906, United States.
• 2British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Division of AIDS, Department of Medicine, University of British Columbia, 667-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
• 3British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
• 4British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Division of AIDS, Department of Medicine, University of British Columbia, 667-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. Electronic address: uhri-mjsm@cfenet.ubc.ca. 
• Addict Behav. 2016 Apr 1;60:8-12. doi: 10.1016/j.addbeh.2016.03.029. 

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The Use of a Brief Mental Health Screener to Enhance the Ability of Police Officers to Identify Persons with Serious Mental Disorders

Police agencies in Canada and elsewhere have received much criticism over how they respond to persons with serious mental disorders. The adequacy of training provided to police officers on mental health issues and in particular on recognizing indicators of serious mental disorders has been a major concern. 

This paper describes the process that led to the development of a new brief mental health screener (interRAI Brief Mental Health Screener, BMHS) designed to assist police officers to better identify persons with serious mental disorders. The interRAI BMHS was developed in collaboration with interRAI, an international, not-for-profit consortium of researchers. The government of Ontario had previously partnered with interRAI to develop and implement the Resident Assessment Instrument for Mental Health (RAI-MH), the assessment system mandated for use on all persons admitted into inpatient psychiatric care in the province. Core items on the interRAI BMHS were obtained through analysis (N=41,019) of RAI-MH data together with input from representatives from health care, police services, and patient groups. 

Two police services in southwestern Ontario completed forms (N=235) on persons thought to have a mental disorder. Patient records were later accessed to determine patient disposition. The use of summary and inferential statistics revealed that the variables significantly associated with being taken to hospital by police included performing a self-injurious act in the past 30days, and others being concerned over the person's risk for self-injury. Variables significantly associated with being admitted included abnormal thought process, delusions, and hallucinations. 

The results of the study indicate that the 14-variable algorithm used to construct the interRAI BMHS is a good predictor of who was most likely to be taken to hospital by police officers and who was most likely to be admitted. The instrument is an effective means of capturing and standardizing police officer observations enabling them to provide more and better quality information to emergency department (ED) staff. 

Teaching police officers to use the form constitutes enhanced training on major indicators of serious mental disorders. Further, given that items on the interRAI BMHS are written in the language of the health system, language acts as common currency between police officers and ED staff laying the foundation for a more collaborative approach between the systems.

Full article at:   http://goo.gl/4FA5EB

By:  Hoffman R1, Hirdes J2, Brown GP3, Dubin JA4, Barbaree H5.

• 1Ministry of Community Safety and Correctional Services, Ontario Police College, 10716 Hacienda Road, Aylmer, Ontario N5H 2T2, Canada; Faculty of Applied and Professional Studies, School of Criminology and Criminal Justice, Nipissing University, 100 College Drive, Box 5002, North Bay, Ontario P1B 8L, Canada. Electronic address: Ron.Hoffman@sympatico.ca.
• 2School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada.
• 3Faculty of Applied and Professional Studies, School of Criminology and Criminal Justice, Nipissing University, 100 College Drive, Box 5002, North Bay, Ontario P1B 8L7, Canada.
• 4Department of Statistics and Actuarial Science, School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada.
• 5Division of Forensic Psychiatry, Department of Psychiatry, University of Toronto, Toronto, Ontario M5T 1R, Canada; Waypoint Centre for Mental Health Care, 500 Church Street, Penetanguishene, Ontario L9M 1G3, Canada. 
• Int J Law Psychiatry. 2016 Apr 1. pii: S0160-2527(16)30044-9. doi: 10.1016/j.ijlp.2016.02.031.

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Bisexuality, Poverty & Mental Health: A Mixed Methods Analysis

Highlights

• Poverty is associated with poor mental health among bisexual people.
• Poverty is also associated with experiences of discrimination among bisexuals.
• Multiple pathways may link bisexuality, poverty, and mental health.
• Lack of affordable culturally competent services may sustain the disparities.

Bisexuality is consistently associated with poor mental health outcomes. In population-based data, this is partially explained by income differences between bisexual people and lesbian, gay, and/or heterosexual individuals. However, the interrelationships between bisexuality, poverty, and mental health are poorly understood. 

In this paper, we examine the relationships between these variables using a mixed methods study of 302 adult bisexuals from Ontario, Canada. Participants were recruited using respondent-driven sampling to complete an internet-based survey including measures of psychological distress and minority stress. A subset of participants completed a semi-structured qualitative interview to contextualize their mental health experiences. 

Using information regarding household income, number of individuals supported by the income and geographic location, participants were categorized as living below or above the Canadian Low Income Cut Off (LICO). Accounting for the networked nature of the sample, participants living below the LICO had significantly higher mean scores for depression and posttraumatic stress disorder symptoms and reported significantly more perceived discrimination compared to individuals living above the LICO. 

Grounded theory analysis of the qualitative interviews suggested four pathways through which bisexuality and poverty may intersect to impact mental health: through early life experiences linked to bisexuality or poverty that impacted future financial stability; through effects of bisexual identity on employment and earning potential; through the impact of class and sexual orientation discrimination on access to communities of support; and through lack of access to mental health services that could provide culturally competent care. 

These mixed methods data help us understand the income disparities associated with bisexual identity in population-based data, and suggest points of intervention to address their impact on bisexual mental health.

Purchase full article at:   http://goo.gl/qFio1c

By:  Ross LE1, O'Gorman L2, MacLeod MA3, Bauer GR3, MacKay J4, Robinson M4.

• 1Dalla Lana School of Public Health, University of Toronto, 155 College St. Room 560, Toronto, Ontario, M5T 3M7, Canada; Social & Epidemiological Research Department, Centre for Addiction & Mental Health, 33 Russell St. Room T406, Toronto, Ontario, M5S 1R8, Canada. Electronic address: l.ross@utoronto.ca.
• 2School of Rural and Northern Health, Laurentian University, 935 Ramsey Lake Rd., Sudbury, Ontario, P3E 2C6, Canada.
• 3Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, Kresge Building Room K201, London, Ontario, N6A 5C1, Canada.
• 4Social & Epidemiological Research Department, Centre for Addiction & Mental Health, 33 Russell St. Room T406, Toronto, Ontario, M5S 1R8, Canada. 
• Soc Sci Med. 2016 Mar 10;156:64-72. doi: 10.1016/j.socscimed.2016.03.009

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Criminal Justice System Contact & Mortality among Offenders with Mental Illness in British Columbia

BACKGROUND:

Persons with mental illness are over-represented in prison populations around the world. They are more vulnerable to arrest and more likely to experience repeated encounters with the criminal justice system. Whether criminal justice involvement, in and of itself, is associated with higher mortality, particularly among offenders with mental illness, is unknown.

METHODS:

The authors conducted a mediation analysis of mortality rates in a cohort of 79,088 offenders from British Columbia using administrative records spanning 2001-2010, where the mediating variable was the individual-level rate of criminal sentencing.

RESULTS:

During 339,506 person-years of follow-up, there were 1841 deaths. The diagnosis of mental illness had no direct association with higher mortality after adjustment for confounders (HR=0.98, 95% CI 0.86 to 1.06). However, mental illness had an indirect association with mortality that was mediated through more frequent criminal justice involvement (HR=1.02, 95% CI 1.01 to 1.04).

CONCLUSIONS:

These findings support the hypothesis that offenders with mental illness experience higher mortality that is mediated by higher rates of criminal justice contact. The results of our study indicate that criminal justice diversion programmes are further warranted because they may contribute to the prevention of mortality among offenders with mental illness.

Purchase full article at:   http://goo.gl/QheVNV

By:  McCandless LC1, Stewart LC1, Rempel ES1, Venners SA1, Somers JM1.

• 1Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada. 

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Prevalence and Co-Occurrence of Heavy Drinking and Anxiety and Mood Disorders among Gay, Lesbian, Bisexual, and Heterosexual Canadians

OBJECTIVES:

To investigate the prevalence and co-occurrence of heavy drinking, anxiety, and mood disorders among Canadians who self-identified as gay, lesbian, bisexual, or heterosexual.

METHODS:

Pooled data from the 2007 to 2012 cycles of the Canadian Community Health Survey (n = 222 548) were used to fit logistic regression models controlling for sociodemographic characteristics.

RESULTS:

In adjusted logistic regression models, gay or lesbian respondents had greater odds than heterosexual respondents of reporting anxiety disorders, mood disorders, and anxiety-mood disorders. Bisexual respondents had greater odds of reporting anxiety disorders, mood disorders, anxiety-mood disorders, and heavy drinking. Gay or lesbian and bisexual respondents had greater odds than heterosexuals of reporting co-occurring anxiety or mood disorders and heavy drinking. The highest rates of disorders were observed among bisexual respondents, with nearly quadruple the rates of anxiety, mood, and combined anxiety and mood disorders relative to heterosexuals and approximately twice the rates of gay or lesbian respondents.

CONCLUSIONS:

Members of sexual minority groups in Canada, in particular those self-identifying as bisexual, experience disproportionate rates of anxiety and mood disorders, heavy drinking, and co-occurring disorders.

Purchase full article at:   http://goo.gl/1nHKaR

By:  Pakula B1, Shoveller J1, Ratner PA1, Carpiano R1.

• 1Basia Pakula is a PhD candidate with the School of Population and Public Health, University of British Columbia, Vancouver. Jean Shoveller is with the School of Population and Public Health, University of British Columbia and the Epidemiology/Population Health and Drug Treatment Program, BC Centre for Excellence in HIV/AIDS, Vancouver. Pamela A. Ratner is with the Faculty of Education and the Enrollment and Academic Facilities, University of British Columbia. Richard Carpiano is with the Department of Sociology, University of British Columbia. 
• Am J Public Health. 2016 Mar 17:e1-e7.

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Housing Outcomes & Predictors of Success: The Role of Hospitalization in Street Outreach

SUMMARY:

What is known on the subject? 

• Outreach services are often successful in engaging and housing street homeless individuals. People experiencing homelessness have greatly increased rates of mental illness and substance abuse. 

What this paper adds to existing knowledge? 

• Given the relative lack of research involving street homeless individuals, this retrospective chart review examined factors associated with successful housing by a multidisciplinary street outreach team, including the use of hospitalization as an intervention within a housing first framework. The majority of clients were successfully housed by the end of outreach team involvement. An admission to hospital was strongly associated with successful housing for those with a psychotic disorder. 

What are the implications for practice? 

• Multidisciplinary outreach teams, specifically those with psychiatric and nursing support, successfully work with and house people experiencing street homelessness and psychosis. Mental health nurses embedded in the community are an essential link between inpatient and outpatient care for highly vulnerable street homeless individuals.

ABSTRACT:

Introduction 
Housing-first strategies have helped establish housing as a human right. However, endemic homelessness persists. Multidisciplinary outreach teams that include nursing, social and psychiatric services allow for integrative strategies to engage and support clients on their housing trajectory. 

The following retrospective review focused on the identification of demographic, clinical, and service characteristics that predicted the obtainment of housing, and explored the role of psychiatric hospitalization as an intervention, not an outcome measure, in contrast to previous studies. These have rarely focused on street homelessness. 

Method
A retrospective chart review of 85 homeless, primarily rough-sleeping, clients was conducted to determine housing outcomes and the factors associated with obtaining housing through care provided by a psychiatric street outreach team in Toronto, Canada. Demographics, homelessness duration, diagnosis, hospitalization and housing status were tracked during team involvement. 

Results 
Overall, 46% (36/79) were housed during the study term. Securing housing at the end of treatment/data collection was significantly enhanced by hospitalization. It was significantly diminished by psychosis and prior homelessness >36 months . Twenty-three of 31 (74%) hospitalized clients with psychosis were subsequently housed, compared to 4 of 30 (13%) not hospitalized. 

Discussion 
Multidisciplinary street outreach teams successfully house long-standing homeless clients (>12 months without a permanent address) with serious mental illness and/or substance abuse. Hospitalization can be utilized as a complimentary intervention, particularly for those with psychosis, in the continuum of housing first initiatives, and can contribute to securing housing for those with persistent psychotic disorders. 

Implications for nursing practice Community mental health nurses are uniquely positioned to translate care between hospital and community settings, ensuring timely assessment, intervention and treatment of clients who are historically difficult to engage.

Purchase full article at:   http://goo.gl/bXs23W

By:  Lettner BH1, Doan RJ2, Miettinen AW3.

• 1Department of Nursing, University of Toronto, Toronto.
• 2Department of Psychiatry, University of Toronto, Toronto.
• 3Department of Economics, University of Toronto, Toronto. 
• J Psychiatr Ment Health Nurs. 2016 Mar;23(2):98-107. doi: 10.1111/jpm.12287.

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Eviction & Loss of Income Assistance among Street-Involved Youth in Canada

Loss of housing and income assistance among vulnerable youth has not been well described in the literature, yet it is a crucial issue for public health. 

This study examines the prevalence and correlates of loss of income assistance as well as eviction among street-involved youth. We collected data from a prospective cohort of street-involved youth aged 14-26. 

Among 770 participants, 64.3 per cent reported having housing and 77.1 per cent reported receiving income assistance at some point during the study period. Further, 28.6 and 20.0 per cent of youth reported having been evicted and losing income assistance, respectively. 

In multivariable generalized estimating equations analysis, heavy alcohol use, unprotected sex, being a victim of violence, and homelessness were all independently associated with eviction. 

Separately, homelessness, recent incarceration, and drug dealing were independently associated with loss of income assistance. 

Eviction and loss of income assistance are common experiences among street-involved youth with multiple vulnerabilities. Our findings highlight the importance of improving continued engagement with critical social services.

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By:  Zivanovic R1,2, Omura J2, Wood E2,3, Nguyen P2, Kerr T2,3, DeBeck K2,4.

• 1University of British Columbia's (UBC) MD program, Vancouver, Canada.
• 2Urban Health Research Initiative, BC Centre of Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St., Vancouver, Canada V6Z 1Y6.
• 3Department of Medicine, University of British Columbia, Vancouver, Canada V5Z 1M9.
• 4School of Public Policy, Simon Fraser University, Vancouver, Canada V6B 5K3.
• J Public Health Policy. 2016 Mar 10. doi: 10.1057/jphp.2016.12. 

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Socioeconomic Marginalisation in the Structural Production of Vulnerability to Violence among People Who Use Illicit Drugs

OBJECTIVE:

Many people who use illicit drugs (PWUD) face challenges to their financial stability. Resulting activities that PWUD undertake to generate income may increase their vulnerability to violence. We therefore examined the relationship between income generation and exposure to violence across a wide range of income generating activities among HIV-positive and HIV-negative PWUD living in Vancouver, Canada.

METHODS:

Data were derived from cohorts of HIV-seropositive and HIV-seronegative PWUD (n=1876) between December 2005 and November 2012. We estimated the relationship between different types of income generation and suffering physical or sexual violence using bivariate and multivariate generalised estimating equations, as well as the characteristics of violent interactions.

RESULTS:

Exposure to violence was reported among 977 (52%) study participants over the study period. In multivariate models controlling for sociodemographic characteristics, mental health status, and drug use patterns, violence was independently and positively associated with participation in street-based income generation activities (ie, recycling, squeegeeing and panhandling), sex work, drug dealing, and theft and other acquisitive criminal activity. Engagement in regular, self-employment or temporary employment was not associated with being exposed to violence. Strangers were the most common perpetrators of violence (46.7%) and beatings the most common type of exposure (70.8%).

CONCLUSIONS:

These results suggest that economic activities expose individuals to contexts associated with social and structural vulnerability to violence. The creation of safe economic opportunities which can minimise vulnerability to violence among PWUD is therefore urgently required.

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By:  Richardson LA1, Long C2, DeBeck K3, Nguyen P4, Milloy MJ5, Wood E5, Kerr TH5.

• 1British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, British Columbia, Canada Department of Sociology, University of British Columbia, Vancouver, British Columbia, Canada.
• 2British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, British Columbia, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
• 3British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, British Columbia, Canada School of Public Policy, Simon Fraser University, Burnaby, British Columbia, Canada.
• 4British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, British Columbia, Canada.
• 5British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, British Columbia, Canada Faculty of Medicine (Division of AIDS), University of British Columbia, British Columbia, Canada. 
• J Epidemiol Community Health. 2015 Jul;69(7):686-92. doi: 10.1136/jech-2014-205079. Epub 2015 Feb 17.

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Implementation Challenges & Opportunities for HIV Treatment as Prevention (TasP) among Young Men in Vancouver, Canada

Background

Despite evidence supporting the preventative potential of HIV Treatment as Prevention (TasP), scientific experts and community stakeholders have suggested that the success of TasP at the population level will require overcoming a set of complex and population-specific implementation challenges. For example, the factors that might influence decisions to initiate ‘early’ treatment have yet to be thoroughly understood; neither have questions about the factors that enhance or impede their ability to achieve long-term adherence to ARVs or the social norms regarding various treatment regimens been examined in detail. This knowledge gap may hamper opportunities to effectively develop public health practices that are informed by the various challenges and opportunities related to TasP implementation and scale up.

Methods

Drawing on 50 in-depth, individual interviews with young men ages 18–24 in Vancouver, Canada, this study examines young men’s perspectives regarding factors that might affect their engagement with TasP.

Results

While findings from the current study indicate young men generally have a high receptiveness to TasP, our findings also identify key social and structural forces that will warrant ongoing consideration for TasP implementation. For example, participants described how an enhanced awareness regarding treatment (including awareness of the universal availability of treatment in Vancouver) would be a necessary, but not sufficient, condition to decide to endorse TasP. Their decisions about engaging in HIV care in the context of TasP (e.g., HIV testing, treatment initiation, long-term adherence) also appear to be contingent on their ability to negotiate or ‘balance’ the risks and benefits to themselves and others. The findings also offer insight into the complex and sometimes controversial narratives that continue to emerge regarding risk compensation practices in the context of TasP.

Conclusion

Based on the results of this study, we identify several areas that hold promise for informing the effective scale up of TasP, including new information regarding implementation adaptation strategies.

[sample of interview responses]

But I don’t know if that [information about HIV treatment and prognoses] makes me any less concerned about certain aspects of the disease just because I also know that it’s [treatment] expensive, and that definitely plays into me, ‘cause I know that if I needed to afford expensive medication, I just couldn’t right now. (#018)

You’re still fucked [in the event of an HIV diagnosis]. I don’t even know if it’s covered by MSP [Medical Services Plan, the provincial health care plan in the province of British Columbia]. I highly doubt it. So if you’re on welfare and you have HIV, I think you’re pretty fucking screwed. And I would not want to have to figure it out, either. (#041)

The person may feel like, ‘Well, you’re only making me undergo treatment because you just wanna protect those around me and decrease their chance of contracting the infection, as opposed to treating me and being concerned about me.’ So I can see the person viewing the measure as ‘all but me.’ (#001)

Full article at:   http://goo.gl/xmw22R

By:  Rod Knight, Will Small, Kim Thomson, Mark Gilbert, and Jean Shoveller

Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada

School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia V6T 1Z3 Canada

British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada

School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia V6T 1Z3 Canada

Ontario HIV Treatment Network, Toronto, Canada

Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

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