Although traditional HIV prevention strategies — behaviour modification, condoms, needle exchange – have been very successful, their effect has reached a plateau since they are not always available, practical, or fully adhered to. In the past five years, research has shown that using antiretroviral therapy (ART) to treat those infected with HIV not only decreases mortality and morbidity but also decreases HIV transmission. Unfortunately, many individuals are still unaware that they are HIV-positive or that they should be on ART, since they have not been linked to our health-care system. These individuals will unnecessarily suffer from their disease and they will incur avoidable hospitalizations, physician visits, and costs.
Dr. Viviane Lima aims to identify different strategies to decrease the public health and economic burdens of HIV in British Columbia (BC). Since individuals living with HIV should follow the same continuum of care from infection until the time of first ART, diminishing the individual and economic burdens of HIV will require a combined effort of different players in our health-care system and the development of a comprehensive strategy to tackle each component in the continuum of care pathway. Lima’s research will employ innovative statistical and mathematical models to analyze these data and compare the potential effects of different complex strategies. This project will create great opportunities for trainees to be supported across a variety of disciplines, further enhancing BC’s competitive advantage in population-health and HIV research. The proposed methodology can also be applied to other diseases, conditions, and settings dealing with similar issues.
HIV treatment has advanced remarkably since 1996, with the advent of highly active antiretroviral therapy (HAART). HAART stops HIV replication and, as a result, the virus is reduced to undetectable levels. This allows immune reconstitution to take place, leading to long-term disease remission and prolonged survival.
The BC Centre for Excellence in HIV/AIDS (BC-CfE) has demonstrated that HAART renders HIV undetectable in sexual fluids and can dramatically reduce HIV transmission. As a result, the BC-CfE is engaged in a number of HIV “treatment as prevention” initiatives aimed at expanding HIV testing and treatment within BC and internationally to decrease HIV-related morbidity and mortality, as well as HIV transmission.
Dr. Bohdan Nosyk’s research is focused on cost-effectiveness analysis of treatment as prevention strategies to inform the most effective allocation of scarce health resources. The initial objective of this proposal is to construct a mathematical cohort simulation model to determine the cost-effectiveness of HAART scale-up in terms of the total costs accumulated, quality adjusted life years, and HIV incidence in BC from 1996 to 2010. A series of statistical and econometric analyses are required to estimate the relevant clinical and economic parameters needed to populate the simulation model. These analyses will be facilitated by the availability of linked administrative datasets and prospectively collected longitudinal data of HAART utilization, duration, and health outcomes at the population level in BC. The analyses will be stratified by HIV acquisition risk factor. This model will be used to predict the potential impact and cost-effectiveness of future policy changes in BC and internationally.
Sex workers in Vancouver have been found to be highly vulnerable to a variety of negative health and safety outcomes, including high rates of occupational and historical violence, a high prevalence of HIV (approximately 25 percent within street-based sex workers in Vancouver), and limited access and use of health services. In order to mitigate some of the HIV and sexually transmitted infection (STI) risk in this population, researchers at the Gender and Sexual Health Initiative at the BC Centre for Excellence in HIV/AIDS are looking into understanding some of the larger structural and environmental determinants of HIV/STI risk. Dr. Kathleen Deering is studying a sample of sex workers in Metropolitan Vancouver to investigate the intersecting relationships between different social, environmental and structural factors, such as the availability and access to health services, neighbourhood of residence, and locations and venues of sex work. She will be measuring health and safety outcomes of these women (such as HIV/STI risks, including inconsistent condom use, number of sex partners and sex partnering patterns, and occupational and intimate partner violence) and the geographic distribution of these outcomes over time. This project will access data from a five-year longitudinal cohort of women in sex work in Vancouver, including 500 women and 250 youth sex workers who are 14 to 24 years of age. Participants will fill out a detailed survey and be asked to provide blood and urine samples for HIV and STI testing at the start and every six months for the five-year duration of the study. Dr. Deering will be using these data, combined with social epidemiology methods and Geographic Information Systems (GIS) mapping technology to help understand how social, structural and environmental factors impact risk patterns for HIV/STI and health services use and access. She will also be exploring the use of complex adaptive systems approaches as a novel and key methodological/analytical approach for examining multiple intersecting levels of risk. The results of this research will lead to important recommendations relating to changes in public health policy and the development of effective safer-environment interventions to improve the health and safety of women in sex work in Canadian settings. Results will be communicated to community members, the local and provincial government, and the study population through ongoing partnerships.
Youth and women working in Vancouver’s sex industry are among the most marginalized and vulnerable in Canadian society. The persistently high rates of health-related issues, violence, and mortality among sex workers, both in Canada and globally, highlights a desperate need for renewed public health interventions targeting the reduction of harms in this industry. Dr. Kate Shannon is working to investigate the different factors influencing the health and safety of youth and women working in the sex industry in Vancouver. Her team is studying the social (violence, work conditions) and structural (laws, regulations, urban renewal) contexts of sexually transmitted infection (STI) in this population. Specifically, her team is examining the different factors that influence the worker’s negotiating power during transactions and how this influences the risk of HIV/STI acquisition. Her research will involve the study and long-term follow-up of two groups of women: (1) 500 existing and new adult women working in both the street and indoor sex industry; and (2) 250 female youth aged 14 to 20 years who have exchanged sex for money, drugs, gifts, shelter, or other commodities in the previous 30 days. By evaluating and integrating different types of data, including individual mapping and neighborhood environment data (including violence and housing) from publicly available sources, she hopes to identify policies and harm-reducing interventions for this population. This study is among the first prospective studies of sex work in North America. Dr. Shannonâs team possesses a wealth of expertise in observational and intervention research, policy, and sex work. They are uniquely positioned to conduct this study, which aims to directly improve the health of some of the most marginalized youth and women in Canadian society.
The development of effective HIV/AIDS treatment has resulted in dramatic improvements in the health of people infected with the virus. Taken regularly, highly active antiretroviral therapy (HAART) interrupts the viral life cycle, suppresses the level of HIV in a patient's bloodstream, and promotes health improvements. The recent finding that individuals undergoing effective treatment are far less likely to transmit the virus to others has spurred the development of a new strategy aimed at preventing new HIV infections. Dubbed "Seek, Test and Treat", the goal of this initiative is to increase the number of people on HIV treatment in Prince George and in Vancouver's Downtown Eastside.
Dr. M-J Milloy is specifically focusing on the expansion of HIV treatment among people of Aboriginal ancestry who use illicit drugs. In Canada, young Aboriginal people are a growing sector of the HIV/AIDS pandemic, and Aboriginal people are highly over-represented among HIV-positive drug users. Dr. Milloy’s research will look at treatment for HIV and health outcomes for Aboriginal drug users and, in light of increasing calls by Aboriginal leaders for research that focuses on health and wellness among Aboriginal people, will try to identify the characteristics of successful treatment.
Dr. Milloy's research will address a number of outstanding concerns:
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Are Aboriginal individuals who are HIV-positive and use illicit drugs being effectively treated with HAART?
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What are some of the broader factors, such as stable housing or employment, that promote effective treatment?
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What is the level of viral resistance to HIV medications among Aboriginal drug users?
Much of the data for this study will come from the AIDS Care Cohort to Evaluate access to Survival Services, an ongoing study of approximately 750 HIV-positive drug users in Vancouver. The research will be supervised by Dr. Evan Adams, Physician Advisor to the First Nations Health Council, who will ensure that the research is respectful and responsible to Aboriginal participants and communities.
The information gained could be used to improve existing systems to provide HAART as well as inform new Aboriginal-led efforts to improve health and wellness. By improving HAART delivery and expanding the number of people receiving effective care for HIV infection, it is hoped that the number of new infections will also drop.
Illicit drug use is associated with severe harms and immense social suffering among youth. Previous ethnographic work has shown how social-structural and cultural processes present within specific urban locales intersect to push young people who engage in drug use towards ‘risk’, until it becomes difficult or impossible for them to avoid transitioning into increasingly ‘risky’ behaviours. However, there have been relatively few in-depth investigations of drug-using contexts or ‘scenes’ that focus exclusively on the meanings, understandings and everyday lived experiences of young drug users themselves. Danya Fast’s research explores young people’s understandings of the social-structural and physical landscapes of the downtown Vancouver drug scene, and how various locales (e.g. neighbourhoods, alleyways, service locations, residences), shape experiences of ‘safety’ and ‘risk’ among drug-using youth. Her approach emphasizes the influence of place on health, where place is understood to encompass both physical and social spaces. An important goal of this research will be the identification of elements in the physical and social environment that shape risk and structural interventions that alter context and, by consequence, facilitate safer spaces for work, rest and recreation for youth. Ms. Fast’s project will result in a more comprehensive and culturally sensitive account of young drug users’ everyday experiences in the context of the downtown Vancouver drug scene, and will also be used to inform ongoing epidemiological research with drug-using youth. Moreover, Ms. Fast’s project will contribute to the development of an ongoing ethno-epidemiological research program that has been identified as an important emergent area within Human Immunodeficiency Virus research, due to its unique ability to inform the development of interventions designed to reduce drug-related harms.
Outside of Africa, an estimated two-thirds of new Human Immunodeficiency virus (HIV), infections are believed to occur among people who inject illicit drugs. While an urgent need exists for tailored interventions to address HIV risk behaviour within vulnerable groups such as adult injection drug users (IDU), there are major knowledge gaps that must first be addressed if interventions are to be successful. Innovative approaches to examine how participation in particular social contexts and environments foster vulnerability to HIV are crucial to the development of effective intervention strategies among highly vulnerable populations of IDUs. William Small is conducting research to address this need using ethnographic methods to develop empirical information regarding transitions into particular high-risk social contexts, including drug markets and sex trade activities. Specifically, his research focuses on the risk environments in two different geographical settings, Vancouver, Canada and Sydney, Australia. The results will provide critical insight regarding how participation in these high-risk settings influences HIV risks as well as an individual’s ability to engage in risk reduction in the context of injection drug use. The information will be integrated with findings from ongoing epidemiological studies in the same locales to test socially-oriented hypotheses regarding the relationship between HIV vulnerabilities and particular social contexts. Ultimately, the findings from Mr. Smallsâ research will help advance the study of HIV risks among IDUs, and inform the development of social and community interventions designed to reduce HIV transmission.
HIV therapy has evolved tremendously due to the development of new drugs, new technologies to measure viral response and drug resistance, and an improved understanding of how the virus progresses in the body. Modern highly active antiretroviral therapies (HAART) suppress the amount of virus circulating in the blood to nearly undetectable levels for long periods, enabling the immune system to rebound, reducing HIV drug resistance and preventing this otherwise fatal disease from progressing. Clinicians have identified that many people on HAART therapies do not fully adhere to the prescribed therapy, and that their level of adherence typically changes over time. This lack of adherence is known to increase the risk of illness and death, but the specifics remain unclear. More information is needed to determine how adherence dynamically affects disease progression and outcomes, so those at higher risk of treatment failure can be identified in advance and helped with their treatment. Dr. Viviane Lima is exploring the relationship between regimen-specific adherence for key HAART therapies and the disease outcomes for patients. She will determine the levels of adherence required at each stage to reduce or prevent a number of disease outcomes: viral rebound, immune cell loss, HIV drug resistance, the emergence of AIDS-related conditions, and death. She hypothesizes that for each disease outcome, there is a distinct, clinically-significant interaction between adherence and type of HAART therapy. Long-term management of HIV/AIDS requires a long-term commitment from patients to adhere to therapy, a high level of expertise among practitioners to deal with complex and rapidly evolving treatments, and the development of clinically meaningful tools to enhance adherence over time and across varied treatments. Limaâs study will provide an evidence base to identify best treatment practices.
A decade ago, HIV infection among downtown eastside residents exceeded those in any other part of the âdevelopedâ world. Current neighbourhood HIV prevalence estimates range between 19 and 22 per cent, and is reported higher amongst individuals who inject drugs. Risk of HIV infection is particularly profound for women who are young, coping with violence and multiple addictions, and whose survival necessitates work in the commercial sex industry. Women and girls are politically, socially and biologically more vulnerable to HIV infection. Many women in the community, including the majority of those who are part of the sex work economy, do access various health and social services, such as clinics, point-of-care and emergency services, as well as needle exchange programs. The use of condoms is also prevalent. Despite this, the rates of HIV infection remain high, particularly among sex workers who are also less likely to be treated for HIV/AIDS. Regardless of income generating strategies, HIV infected women in the community face multiple barriers to continuity of care. Suze Berkhout was previously funded by MSFHR for her early PhD work in HIV risk behaviours and health service needs among women in Vancouverâs inner city. Employing qualitative research methods and philosophical analysis, her research critically examines the impact of common stereotypes, life histories, and institutional norms and values on womenâs health care experiences, in order to unravel the paradox surrounding the health and well-being of vulnerable women. Rather than suggest that women who appear to systematically “”choose”” poor health are irrational or irresponsible, Berkhoutâs study seeks to understand what health trade-offs women may make in the context of their lives. For example, day-to-day concerns such as housing, food or caring for others may take precedence over health concerns. Likewise, womenâs previous experiences in the health system may themselves perpetuate mistrust toward health providers, leading to delays and discontinuation of medical care. Berkhoutâs findings will enable health care providers to better reflect on and respond to the experiences of patients within the health care system. Ultimately, her work could lead to more appropriate and responsive care for socially and economically disadvantaged women.
The introduction in the mid-1990s of highly active antiretroviral therapy (HAART) helped HIV become a manageable disease in industrialized settings such as Canada. Mortality and morbidity associated with HIV have been dramatically reduced with the increased use of these drug regimens and are associated with reduced transmission probability of HIV within sexual relationships. It has been proposed that HAART be integrated into HIV-prevention activities as a means of helping curb epidemic growth. Evaluating the impact of HAART is complex. For example, while the effect of reduced symptoms and increased lifespan is beneficial to the individual, modelling studies have shown that unless infectiousness of individuals is sufficiently reduced by antiretrovirals, the negative impact of an increased incubation period (leading to increased number of opportunities for transmitting infection and a larger population of transmitters) can actually increase how fast the infection spreads. Using mathemathical modelling methods, Kathleen Deering is comparing the impacts of HAART in Vancouver (where HIV-infected individuals have free access to treatment), and in southwest India (where only about 10 per cent of HIV-infected people have access). Her studies, which consider infection biology, behavioural and demographic characteristics of the population, and the spread of infection over time, will be used to compare different treatment strategies for HAART, and to project disease outcomes. Deeringâs research will provide evidence for developing HIV treatment and care recommendations that will help maximize the effectiveness of HAART among marginalized groups in Canada and India.
