Publications by authors named "Hasina Samji"

63 Publications

Women in the 2019 hepatitis C cascade of care: findings from the British Columbia Hepatitis Testers cohort study.

BMC Womens Health 2021 Sep 13;21(1):330. Epub 2021 Sep 13.

British Columbia Centre for Disease Control, Vancouver, BC, Canada.

Background: Women living with hepatitis C virus (HCV) are rarely addressed in research and may be overrepresented within key populations requiring additional support to access HCV care and treatment. We constructed the HCV care cascade among people diagnosed with HCV in British Columbia, Canada, as of 2019 to compare progress in care and treatment and to assess sex/gender gaps in HCV treatment access.

Methods: The BC Hepatitis Testers Cohort includes 1.7 million people who tested for HCV, HIV, reported cases of hepatitis B, and active tuberculosis in BC from 2000 to 2019. Test results were linked to medical visits, hospitalizations, cancers, prescription drugs, and mortality data. Six HCV care cascade stages were identified: (1) antibody diagnosed; (2) RNA tested; (3) RNA positive; (4) genotyped; (5) initiated treatment; and (6) achieved sustained virologic response (SVR). HCV care cascade results were assessed for women, and an 'inverse' cascade was created to assess gaps, including not being RNA tested, genotyped, or treatment initiated, stratified by sex.

Results: In 2019, 52,638 people with known sex were anti-HCV positive in BC; 37% (19,522) were women. Confirmatory RNA tests were received by 86% (16,797/19,522) of anti-HCV positive women and 83% (27,353/33,116) of men. Among people who had been genotyped, 68% (6756/10,008) of women and 67% (12,640/18,828) of men initiated treatment, with 94% (5023/5364) of women and 92% (9147/9897) of men achieving SVR. Among the 3252 women and 6188 men not yet treated, higher proportions of women compared to men were born after 1975 (30% vs. 21%), had a mental health diagnosis (42% vs. 34%) and had used injection drugs (50% vs. 45%). Among 1619 women and 2780 men who had used injection drugs and were not yet treated, higher proportions of women than men used stimulants (64% vs. 57%), and opiates (67% vs. 60%).

Conclusions: Women and men appear to be equally engaged into the HCV care cascade; however, women with concurrent social and health conditions are being left behind. Treatment access may be improved with approaches that meet the needs of younger women, those with mental health diagnoses, and women who use drugs.
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http://dx.doi.org/10.1186/s12905-021-01470-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8436483PMC
September 2021

Review: Mental health impacts of the COVID-19 pandemic on children and youth - a systematic review.

Child Adolesc Ment Health 2021 Aug 28. Epub 2021 Aug 28.

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

Background: The COVID-19 pandemic has posed an unprecedented threat to global mental health. Children and adolescents may be more susceptible to mental health impacts related to their vulnerable developmental stage, fear of infection, home confinement, suspension of regular school and extracurricular activities, physical distancing mandates, and larger scale threats such as global financial recessions and associated impacts. Our objective was to review existing evidence of the COVID-19 pandemic's global impact on the mental health of children and adolescents <19 years of age and to identify personal and contextual factors that may enhance risk or confer protection in relation to mental health outcomes.

Methods: We conducted a search of peer-reviewed and preprint research published in English from January 1, 2020, to February 22, 2021. We included studies collecting primary data on COVID-19-related mental health impacts on children and adolescents. We graded the strength of included articles using the Oxford Centre for Evidence-Based Medicine rating scheme.

Results: Our search and review yielded 116 articles presenting data on a total of 127,923 children and adolescents; 50,984 child and adolescent proxy reports (e.g., parents, healthcare practitioners); and >3,000 chart reviews. A high prevalence of COVID-19-related fear was noted among children and adolescents, as well as more depressive and anxious symptoms compared with prepandemic estimates. Older adolescents, girls, and children and adolescents living with neurodiversities and/or chronic physical conditions were more likely to experience negative mental health outcomes. Many studies reported mental health deterioration among children and adolescents due to COVID-19 pandemic control measures. Physical exercise, access to entertainment, positive familial relationships, and social support were associated with better mental health outcomes.

Conclusions: This review highlights the urgent need for practitioners and policymakers to attend to and collaborate with children and adolescents, especially those in higher risk subgroups, to mitigate short- and long-term pandemic-associated mental health effects.
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http://dx.doi.org/10.1111/camh.12501DOI Listing
August 2021

The impact of current opioid agonist therapy on hepatitis C virus treatment initiation among people who use drugs from in the DAA era: A population-based study.

Clin Infect Dis 2021 Jun 14. Epub 2021 Jun 14.

British Columbia Centre for Disease Control, Vancouver, BC, Canada.

Background: Evidence that opioid agonist therapy (OAT) is associated with increased odds of hepatitis C virus (HCV) treatment initiation among people who use drugs (PWUD) is emerging. The objective of this study was to determine the association between current OAT and HCV treatment initiation among PWUD in a population-level linked administrative dataset.

Methods: The British Columbia (BC) Hepatitis Testers Cohort was used for this study, which includes all people tested for or diagnosed with HCV in BC, linked to medical visits, hospitalizations, laboratory, prescription drug, and mortality data from 1992 until 2019. PWUD with injecting drug use or opioid use disorder and chronic HCV infection were identified for inclusion in this study. HCV treatment initiation was the main outcome, and subdistribution proportional hazards modeling was used to assess the relationship with current OAT.

Results: 13,803 PWUD with chronic HCV were included in this study. Among those currently on OAT at the end of the study period, 47% (2,704/5,770) had started HCV treatment, whereas 22% (1778/8033) of those not currently on OAT has started HCV treatment .. Among PWUD with chronic HCV infection, current OAT was associated with higher likelihood of HCV treatment initiation in time to event analysis (adjusted hazard ratio 1.84 [95%CI, 1.50, 2.26]).

Conclusions: Current OAT was associated with a higher likelihood of HCV treatment initiation. However, many PWUD with HCV currently receiving OAT have yet to receive HCV treatment. Enhanced integration between substance use care and HCV treatment is needed to improve the overall health of PWUD.
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http://dx.doi.org/10.1093/cid/ciab546DOI Listing
June 2021

Impact of HCV infection and ethnicity on incident type 2 diabetes: findings from a large population-based cohort in British Columbia.

BMJ Open Diabetes Res Care 2021 06;9(1)

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

Introduction: Increasing evidence indicates that chronic hepatitis C virus (HCV) infection is associated with higher risk of diabetes. Previous studies showed ethnic disparities in the disease burden of diabetes, with increased risk in Asian population. We described the incidence of type 2 diabetes related to HCV infection and assessed the concurrent impact of HCV infection and ethnicity on the risk of diabetes.

Research Design And Methods: In British Columbia Hepatitis Testers Cohort, individuals were followed from HCV diagnosis to the earliest of (1) incident type 2 diabetes, (2) death or (3) end of the study (December 31, 2015). Study population included 847 021 people. Diabetes incidence rates in people with and without HCV were computed. Propensity scores (PS) analysis was used to assess the impact of HCV infection on newly acquired diabetes. PS-matched dataset included 117 184 people. We used Fine and Gray multivariable subdistributional hazards models to assess the effect of HCV and ethnicity on diabetes while adjusting for confounders and competing risks.

Results: Diabetes incidence rates were higher among people with HCV infection than those without. The highest diabetes incidence rate was in South Asians with HCV (14.7/1000 person-years, 95% CI 12.87 to 16.78). Compared with Others, South Asians with and without HCV and East Asians with HCV had a greater risk of diabetes. In the multivariable stratified analysis, HCV infection was associated with increased diabetes risk in all subgroups: East Asians, adjusted HR (aHR) 3.07 (95% CI 2.43 to 3.88); South Asians, aHR 2.62 (95% CI 2.10 to 3.26); and Others, aHR 2.28 (95% CI 2.15 to 2.42).

Conclusions: In a large population-based linked administrative health data, HCV infection was associated with higher diabetes risk, with a greater relative impact in East Asians. South Asians had the highest risk of diabetes. These findings highlight the need for care and screening for HCV-related chronic diseases such as type 2 diabetes among people affected by HCV.
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http://dx.doi.org/10.1136/bmjdrc-2021-002145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8186745PMC
June 2021

Impact of direct-acting antivirals for HCV on mortality in a large population-based cohort study.

J Hepatol 2021 Jun 25. Epub 2021 Jun 25.

British Columbia Centre for Disease Control, Vancouver, BC, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.

Background & Aims: We evaluated the effect of direct-acting antiviral (DAA)-induced sustained virologic response (SVR) on all-cause, liver- and drug-related mortality in a population-based cohort in British Columbia, Canada.

Methods: We used data from the British Columbia Hepatitis Testers Cohort, which includes people tested for HCV since 1990, linked with data on medical visits, hospitalizations, prescription drugs and mortality. We followed people who received DAAs and people who did not receive any HCV treatment to death or December 31, 2019. We used inverse probability of treatment weighting to balance the baseline profile of treated and untreated individuals and performed multivariable proportional hazard modelling to assess the effect of DAAs on mortality.

Results: Our cohort comprised 10,851 people treated with DAAs (SVR 10,426 [96%], no-SVR: 425) and 10,851 matched untreated individuals. Median follow-up time was 2.2 years (IQR 1.3-3.6; maximum 6.2). The all-cause mortality rate was 19.5/1,000 person-years (PY) among the SVR group (deaths = 552), 86.5/1,000 PY among the no-SVR group (deaths = 96), and 99.2/1,000 PY among the untreated group (deaths = 2,133). In the multivariable model, SVR was associated with significant reduction in all-cause (adjusted hazard ratio [aHR] 0.19; 95% CI 0.17-0.21), liver- (adjusted subdistribution HR [asHR] 0.22, 95% CI 0.18-0.27) and drug-related mortality (asHR 0.26, 95% CI 0.21-0.32) compared to no-treatment. Older age and cirrhosis were associated with higher risk of liver-related mortality while younger age, injection drug use (IDU), problematic alcohol use and HIV/HBV co-infections were associated with a higher risk of drug-related mortality.

Conclusions: DAA treatment is associated with a substantial reduction in all-cause, liver- and drug-related mortality. The association of IDU and related syndemic factors with a higher risk of drug-related mortality calls for an integrated social support, addiction, and HCV care approach among people who inject drugs.

Lay Summary: We assessed the effect of treatment of hepatitis C virus infection with direct-acting antiviral drugs on deaths from all causes, liver disease and drug use. We found that treatment with direct-acting antiviral drugs is associated with substantial lowering in risk of death from all causes, liver disease and drug use among people with hepatitis C virus infection.
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http://dx.doi.org/10.1016/j.jhep.2021.05.028DOI Listing
June 2021

Prevalence of co-occurring mental illness and substance use disorder and association with overdose: a linked data cohort study among residents of British Columbia, Canada.

Addiction 2021 May 25. Epub 2021 May 25.

Clinical Prevention Services, BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, British Columbia, Canada.

Aims: To estimate the treated prevalence of mental illness, substance use disorder (SUD) and dual diagnosis and the association between dual diagnosis and fatal and non-fatal overdose among residents of British Columbia (BC), Canada.

Design: A retrospective cohort study using linked health, income assistance, corrections and death records.

Setting: British Columbia (BC), Canada.

Participants: A total of 921 346 BC residents (455 549 males and 465 797 females) aged 10 years and older.

Measurements: Hospital and primary-care administrative data were used to identify a history of mental illness only, SUD only, dual diagnosis or no history of SUD or mental illness (2010-14) and overdoses resulting in medical care (2015-17). We calculated crude incidence rates of non-fatal and fatal overdose by dual diagnosis history. Andersen-Gill and competing risks regression were used to examine the association between dual diagnosis and non-fatal and fatal overdose, respectively, adjusting for age, sex, comorbidities, incarceration history, social assistance, history of prescription opioid and benzodiazepine dispensing and region of residence.

Findings: Of the 921 346 people in the cohort, 176 780 (19.2%), 6147 (0.7%) and 15 269 (1.7%) had a history of mental illness only, SUD only and dual diagnosis, respectively; 4696 (0.5%) people experienced 688 fatal and 6938 non-fatal overdoses. In multivariable analyses, mental illness only, SUD only and dual diagnosis were associated with increased rate of non-fatal [hazard ratio (HR) = 1.8, 95% confidence interval (CI) = 1.6-2.1; HR = 9.0, 95% CI = 7.0-11.5, HR = 8.7, 95% CI = 6.9-10.9, respectively] and fatal overdose (HR = 1.6, 95% CI = 1.3-2.0, HR = 4.3, 95% CI = 2.8-6.5, HR = 4.1, 95% CI = 2.8-6.0, respectively) compared with no history.

Conclusions: In a large sample of residents of British Columbia (Canada), approximately one in five people had sought care for a substance use disorder or mental illness in the past 5 years. The rate of overdose was elevated in people with a mental illness alone, higher again in people with a substance use disorder alone and highest in people with a dual diagnosis. The adjusted hazard rates were similar for people with substance use disorder only and people with a dual diagnosis.
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http://dx.doi.org/10.1111/add.15580DOI Listing
May 2021

Estimating the Prevalence of Mental and Substance Use Disorders: A Systematic Approach to Triangulating Available Data to Inform Health Systems Planning:: Estimer la prévalence des troubles mentaux et des troubles liés à une substance: une approche systématique de la triangulation des données disponibles pour éclairer la planification du système de santé.

Can J Psychiatry 2021 Apr 8:7067437211006872. Epub 2021 Apr 8.

Centre for Applied Research in Mental Health and Addictions, Simon Fraser University, Vancouver, British Columbia, Canada.

Objective: To estimate the prevalence of specific mental and substance use disorders (MSUDs), by age and sex, as a first step toward informing needs-based health systems planning by decision-makers.

Methods: We developed a conceptual framework and a systematic methodology for combining available data sources to yield prevalence estimates for specific MSUDs. Data sources used included published, peer-reviewed literature from Canada and comparable countries, Canadian population survey data, and health administrative data from British Columbia. Several well-established methodologies including systematic review and meta-analyses of published prevalence estimates, modelling of age- and sex-specific distributions, and the Global Burden of Disease severity distribution model were incorporated in a novel mode of triangulation.

Results: Using this novel approach, we obtained prevalence estimates for 10 MSUDs for British Columbia, Canada, as well as prevalence distributions across age groups, by sex.

Conclusion: Obtaining reliable assessments of disorder prevalence and severity is a useful first step toward rationally estimating service need and plan health services. We propose a methodology to leverage existing information to obtain robust estimates in a timely manner and with sufficient granularity to, after adjusting for comorbidity and matching with severity-specific service bundles, inform need-based planning efforts for adult (15 years and older) mental health and substance use services.
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http://dx.doi.org/10.1177/07067437211006872DOI Listing
April 2021

Differences in risk factors for hepatitis B, hepatitis C, and human immunodeficiency virus infection by ethnicity: A large population-based cohort study in British Columbia, Canada.

Int J Infect Dis 2021 May 23;106:246-253. Epub 2021 Mar 23.

British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada; School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.

Objectives: Addressing the needs of ethnic minorities will be key to finding undiagnosed individuals living with hepatitis B (HBV), hepatitis C (HCV), or human immunodeficiency virus (HIV). To inform screening initiatives in British Columbia (BC), Canada, the factors associated with HBV and/or HCV and/or HIV infection among different ethnic groups within a large population-based cohort were assessed.

Methods: Persons diagnosed with HBV, HCV, or HIV in BC between 1990 and 2015 were grouped as East Asian, South Asian, Other Visible Minority (African, Central Asian, Latin American, Pacific Islander, West Asian, unknown ethnicity), and Not a Visible Minority, using a validated name-recognition software. Factors associated with infection within each ethnic group were assessed with multivariable multinomial logistic regression models.

Results: Participants included 202 521 East Asians, 126 070 South Asians, 65 210 Other Visible Minorities, and 1 291 561 people who were Not a Visible Minority, 14.4%, 3.3%, 4.5%, and 6.3% of whom had HBV and/or HCV and/or HIV infections, respectively. Injection drug use was most prevalent among infection-positive people who were Not a Visible Minority (22.1%), and was strongly associated with HCV monoinfection, HBV/HCV coinfection, and HCV/HIV coinfection, but not with HBV monoinfection among visible ethnic minorities. Extreme material deprivation and social deprivation were more prevalent than injection drug use or problematic alcohol use among visible ethnic minorities.

Conclusions: Risk factor distributions varied among persons diagnosed with HBV and/or HCV and/or HIV of differing ethnic backgrounds, with lower substance use prevalence among visible minority populations. This highlights the need for tailored approaches to infection screening among different ethnic groups.
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http://dx.doi.org/10.1016/j.ijid.2021.03.061DOI Listing
May 2021

Building Bridges: Describing a Process for Indigenous Engagement in Epidemiology.

Prog Community Health Partnersh 2020 ;14(4):461-470

Background: Processes for epidemiology embedded with Indigenous methodology are needed. Building Bridges was developed to engage Indigenous peoples in epidemiology to address health issues relevant to them.

Objectives: We describe our process for meaningfully engaging Indigenous leaders and peoples living with human immunodeficiency virus (HIV) in epidemiology research.

Methods: As a community-based research (CBR) project, Indigenous methodologies and leadership ensured the quality and relevance of findings. Study phases included 1) advisory board formation, 2) recruitment, 3) research question identification, 4) data analysis from the Canadian HIV Observational Cohort (CANOC) collaboration, 5) data interpretation and contextualization, and 6) knowledge translation and exchange.

Lessons Learned: Support and guidance from Indigenous team members, Spiritual Leaders and Elders along with meaningful relationships with allied academic researchers were pivotal. Expertise and lived experiences in Indigenous culture, HIV, epidemiology and services enabled multidirectional learning.

Conclusions: Building Bridges' success hinged on ongoing co-learning and engagement of Indigenous peoples, service providers and researchers.
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http://dx.doi.org/10.1353/cpr.2020.0051DOI Listing
January 2020

Drug-related deaths in a population-level cohort of people living with and without hepatitis C virus in British Columbia, Canada.

Int J Drug Policy 2020 Oct 19;86:102989. Epub 2020 Oct 19.

British Columbia Centre for Disease Control, 655 West 12(th) Avenue, Vancouver, British Columbia, Canada, V5Z 4R4; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, British Columbia, Canada, V6T 1Z3.

Background: The majority of new HCV infections in Canada occur in people who inject drugs. Thus, while curative direct antiviral agents (DAAs) herald a promising new era in hepatitis C virus (HCV) treatment, improving the lives and wellbeing of people living with HCV (PLHCV) must be considered in the context of reducing overdose-related harms and with a syndemic lens. We measure drug-related deaths (DRDs) among HCV-negative people and PLHCV in British Columbia (BC), Canada, and the impact of potent contaminants like fentanyl on deaths.

Methods: We identified DRDs among PLHCV and HCV-negative individuals from 2010 to 2018 in the BC Hepatitis Testers Cohort, a population-based dataset of ~1.7 million British Columbians comprising comprehensive administrative and clinical data. We estimated annual standardized liver- and drug-related mortality rates per 100,000 person-years (PY) and described the contribution of specific drugs, including fentanyl and its analogues, implicated in DRDs over time.

Results: DRDs constituted 20.1% of deaths among PLHCV and 4.7% of deaths among HCV-negative individuals; a 4.3-fold (95% confidence interval: 4.0-4.5) difference. Drug-related mortality overtook liver-related mortality for PLHCV in 2015 and HCV-negative individuals in 2016 and rose from 241.7 to 436.5 per 100,000 PY from 2010 to 2018 amongPLHCV and from 20.0 to 57.1 per 100,000 PY for HCV-negative individuals over the same period. The proportion of deaths attributable to drugs among PLHCV and HCV-negative individuals increased from 15.1% to 26.1% and 3.1% to 8.0%, in 2010 and 2018, respectively. The proportion of DRDs attributed solely to synthetic opioids such as fentanyl averaged across both groups increased from 2.1% in 2010 to 69.6% in 2017.

Conclusion: Steep drug-related mortality increases among PLHCV and HCV-negative individuals over the last decade highlight the urgent need to address overdose-related drivers and harms in these populations using an integrated care approach.
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http://dx.doi.org/10.1016/j.drugpo.2020.102989DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7569420PMC
October 2020

Risk of overdose-related death for people with a history of incarceration.

Addiction 2021 06 27;116(6):1460-1471. Epub 2020 Nov 27.

British Columbia Centre for Disease Control, Vancouver, BC, Canada.

Background And Aims: Reported associations between previous incarceration and the risk of overdose-related death are substantially heterogeneous, and previous studies are limited by an inability to control for confounding factors in risk assessment. This study investigated the associations of overdose-related death with previous incarceration and the number or cumulative duration of previous incarcerations, and individual or neighborhood characteristics that may potentially modify the associations.

Design And Setting: A cohort study using a 20% random sample of residents in British Columbia, Canada.

Participants: A total of 765 690 people aged 23 years or older at baseline as of 1 January 2015. Mean age was 50 years; 49% were males.

Measurements: Previous incarcerations that occurred during the 5-year exposure period (January 2010 to December 2014) were identified using provincial incarceration records. Overdose-related deaths that occurred during the 3-year follow-up period (January 2015 to December 2017) were identified using linked administrative health data. Baseline individual and neighborhood characteristics were retrieved from the provincial health insurance data.

Findings: In the cohort, 5743 people had an incarceration history during the exposure period, and 634 people died from drug overdose during the follow-up period. The mortality rate was 897 and 22 per 100 000 person-years for people who did and did not have an incarceration history, respectively. After adjusting for baseline individual and neighborhood characteristics (without any interaction term), people who had an incarceration history were 4.04 times (95% confidence interval 3.23-5.06) more likely to die from drug overdose compared with people without an incarceration history. The association was stronger for females, people without diagnoses of substance use disorder and people without dispensation of opioids for pain or benzodiazepines (P < 0.001 for each interaction term). There was no discernible linear trend between the number or cumulative duration of previous incarcerations and the risk of overdose-related death.

Conclusions: Previous incarceration appears to be a major risk factor for overdose-related death.
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http://dx.doi.org/10.1111/add.15293DOI Listing
June 2021

Climate anxiety in young people: a call to action.

Lancet Planet Health 2020 10 9;4(10):e435-e436. Epub 2020 Sep 9.

Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada; British Columbia Centre for Disease Control, Vancouver, BC, Canada. Electronic address:

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http://dx.doi.org/10.1016/S2542-5196(20)30223-0DOI Listing
October 2020

Syndemic profiles of people living with hepatitis C virus using population-level latent class analysis to optimize health services.

Int J Infect Dis 2020 Nov 15;100:27-33. Epub 2020 Aug 15.

School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada; BC Centre for Disease Control, Vancouver, BC, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada. Electronic address:

Background: Hepatitis C (HCV) affects diverse populations such as people who inject drugs (PWID), 'baby boomers,' gay/bisexual men who have sex with men (gbMSM), and people from HCV endemic regions. Assessing HCV syndemics (i.e.relationships with mental health/chronic diseases) among subpopulations using Latent Class Analysis (LCA) may facilitate targeted program planning.

Methods: The BC Hepatitis Testers Cohort(BC-HTC) includes all HCV cases identified in BC between 1990 and 2015, integrated with medical administrative data. LCA grouped all BC-HTC HCV diagnosed people(n = 73,665) by socio-demographic/clinical indicators previously determined to be relevant for HCV outcomes. The final model was chosen based on fit statistics, epidemiological meaningfulness, and posterior probability. Classes were named by most defining characteristics.

Results: The six-class model was the best fit and had the following names and characteristics: 'Younger PWID'(n =11,563): recent IDU (67%), people born >1974 (48%), mental illness (62%), material deprivation (59%). 'Older PWID'(n =15,266): past IDU (78%), HIV (17%), HBV (17%) coinfections, alcohol misuse(68%). 'Other Middle-Aged People'(n = 9019): gbMSM (26%), material privilege (31%), people born between 1965-1974 (47%). 'People of Asian backgrounds' (n = 4718): East/South Asians (92%), no alcohol misuse (97%) or mental illness (93%), people born <1945 (26%), social privilege (66%). 'Rural baby boomers' (n = 20,401): rural dwellers (32%), baby boomers (79%), heterosexuals (99%), no HIV (100%). 'Urban socially deprived baby boomers' (n = 12,698): urban dwellers (99%), no IDU (100%), liver disease (22%), social deprivation (94%).

Conclusions: Differences between classes suggest variability in patients' service needs. Further analysis of health service utilization patterns may inform optimal service layout.
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http://dx.doi.org/10.1016/j.ijid.2020.08.035DOI Listing
November 2020

Factors associated with interest in bacterial sexually transmitted infection vaccines at two large sexually transmitted infection clinics in British Columbia, Canada.

Sex Transm Infect 2020 Nov 26;96(7):494-500. Epub 2020 May 26.

British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.

Objective: To explore sexually transmitted infection (STI) clinic client attitudes and preferences towards STI vaccines and STI vaccine programming in an urban clinic setting.

Methods: A 31-item questionnaire was administered during check-in by clinic clerical staff at two STI clinics in Vancouver, Canada. Demographic characteristics and preferences were summarised descriptively. Multivariable logistic regression models to assess factors associated with STI vaccine interest (reported as ORs) were constructed using a priori clinically relevant variables and factors significant at p≤0.05 in bivariate analysis.

Results: 293 surveys were included in analysis. 71.3% of respondents identified as male, 80.5% had college level education or higher and 52.9% identified as white/of European descent. The median age was 33. 86.5% of respondents reported they would be interested in receiving an STI vaccine, with a primary motivator to protect oneself. Bivariate analysis indicated several factors associated with vaccine interest, with differences for each infection. After adjusting for other variables, willingness to pay for an STI vaccine (OR=3.83, 95% CI 1.29 to 11.38, p=0.02) remained a significant factor for syphilis vaccine interest and intent to engage in future positive health behaviours remained a significant factor for chlamydia (OR=5.94, 95% CI 1.56 to 22.60, p=0.01) and gonorrhoea (OR=5.13, 95% CI 1.45 to 18.07, p=0.01) vaccine interest.

Conclusion: Respondents expressed a strong willingness to receive STI vaccines. These valuable findings will inform for eventual STI vaccine programme planning and implementation.
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http://dx.doi.org/10.1136/sextrans-2019-054311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591709PMC
November 2020

Loss to follow-up: A significant barrier in the treatment cascade with direct-acting therapies.

J Viral Hepat 2020 03 2;27(3):243-260. Epub 2019 Dec 2.

BC Centre for Disease Control, Vancouver, BC, Canada.

Effectiveness of direct-acting antiviral (DAA) therapies could be influenced by patient characteristics such as comorbid conditions, which could lead to premature treatment discontinuation and/or irregular medical follow-ups. Here, we evaluate loss to follow-up and treatment effectiveness of sofosbuvir/ledipasvir ± ribavirin (SOF/LDV ± RBV), ombitasvir/paritaprevir/ritonavir + dasabuvir ± ribavirin (OBV/PTV/r + DSV ± RBV) for hepatitis C virus (HCV) genotype 1 (GT1) and sofosbuvir + ribavirin (SOF + RBV) for genotype 3 (GT3) in British Columbia Canada: The British Columbia Hepatitis Testers Cohort includes data on individuals tested for HCV since 1992, integrated with medical visit, hospitalization and prescription drug data. HCV-positive individuals who initiated DAA regimens, irrespective of treatment completion, for GT1 and GT3 until 31 December, 2017 were included. Factors associated with sustained virological response (SVR) and loss to follow-up were assessed by using multivariable logistic regression models. In total 4477 individuals initiated DAAs. The most common prescribed DAA was SOF/LDV ± RBV with SVR of 95%. The highest SVR of 99.5% was observed among OBV/PTV/r + DSV-treated patients. Overall, 453 (10.1%) individuals were lost to follow-up. Higher loss to follow-up was observed among GT1 patients treated with OBV (17.8%) and GT3 patients (15.7%). The loss to follow-up rate was significantly higher among individuals aged <60 years, those with a history of injection drug use (IDU), on opioid substitution therapy and with cirrhosis. Our findings indicate that loss to follow-up exceeds viral failure in HCV DAA therapy and its rate varies significantly by genotype and treatment regimen. Depending on the aetiology of lost to follow-up, personalized case management for those with medical complications and supporting services among IDU are needed to achieve the full benefits of effective treatments.
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http://dx.doi.org/10.1111/jvh.13228DOI Listing
March 2020

Reply to: "Pitfalls in measuring temporal trends for late diagnosis of viral hepatitis".

J Hepatol 2019 12 23;71(6):1256-1258. Epub 2019 Oct 23.

British Columbia Centre for Disease Control, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jhep.2019.09.015DOI Listing
December 2019

Sustained virological response from interferon-based hepatitis C regimens is associated with reduced risk of extrahepatic manifestations.

J Hepatol 2019 12 6;71(6):1116-1125. Epub 2019 Aug 6.

British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada; School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Background & Aims: HCV infection is associated with several extrahepatic manifestations (EHMs). We evaluated the impact of sustained virological response (SVR) on the risk of 7 EHMs that contribute to the burden of extrahepatic disease: type 2 diabetes mellitus, chronic kidney disease or end-stage renal disease, stroke, ischemic heart disease, major adverse cardiac events, mood and anxiety disorders, and rheumatoid arthritis.

Methods: A longitudinal cohort study was conducted using data from the British Columbia Hepatitis Testers Cohort, which included ~1.3 million individuals screened for HCV. We identified all HCV-infected individuals who were treated with interferon-based therapies between 1999 and 2014. SVR was defined as a negative HCV RNA test ≥24 weeks post-treatment or after end-of-treatment, if unavailable. We computed adjusted subdistribution hazard ratios (asHR) for the effect of SVR on each EHM using competing risk proportional hazard models. Subgroup analyses by birth cohort, sex, injection drug exposure and genotype were also performed.

Results: Overall, 10,264 HCV-infected individuals were treated with interferon, of whom 6,023 (59%) achieved SVR. Compared to those that failed treatment, EHM risk was significantly reduced among patients with SVR for type 2 diabetes mellitus (asHR 0.65; 95%CI 0.55-0.77), chronic kidney disease or end-stage renal disease (asHR 0.53; 95% CI 0.43-0.65), ischemic or hemorrhagic stroke (asHR 0.73; 95%CI 0.49-1.09), and mood and anxiety disorders (asHR 0.82; 95%CI 0.71-0.95), but not for ischemic heart disease (asHR 1.23; 95%CI 1.03-1.47), major adverse cardiac events (asHR 0.93; 95%CI 0.79-1.11) or rheumatoid arthritis (asHR 1.09; 95% CI 0.73-1.64).

Conclusions: SVR was associated with a reduction in the risk of several EHMs. Increased uptake of antiviral therapy may reduce the growing burden of EHMs in this population.

Lay Summary: We estimated the rates of chronic comorbidities other than liver disease between those who were cured and those who failed treatment for hepatitis C virus (HCV) infection. Our findings showed that the rates of these non-liver diseases were largely reduced for those who were cured with interferon-based treatments. Early HCV treatments could provide many benefits in the prevention of various HCV complications beyond liver disease.
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http://dx.doi.org/10.1016/j.jhep.2019.07.021DOI Listing
December 2019

Incidence of select chronic comorbidities among a population-based cohort of HIV-positive individuals receiving highly active antiretroviral therapy.

Curr Med Res Opin 2019 11 26;35(11):1955-1963. Epub 2019 Aug 26.

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

To characterize the incidence of select chronic comorbidities in the era of modern (pre-integrase-inhibitor) highly active antiretroviral therapy (HAART) in British Columbia, Canada. We used data from the Comparative Outcomes And Service Utilization Trends (COAST) study, a population-based cohort study of people living with HIV (PLWH), to determine incidence rates of six key chronic diseases among PLWH receiving HAART in BC from 2000 to 2012. The selected diseases included cardiovascular disease (CVD), diabetes mellitus (DM), hypertension (HTN), asthma/chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) and chronic liver disease (CLD) defined using ICD-9 and -10 codes. Disease incidence was determined by number of new cases per year. We used Poisson regression to measure trends in incidence rates. The study sample ( 10,210) was predominantly male (83%), white (72%) and younger than 50 years of age at HAART initiation (88%). Incidence rates of HTN per 1000 person-years (PY) increased significantly between 2000 and 2012, after adjusting for age, sex, baseline-weighted Charlson Comorbidity Index, CD4 cell count and viral load ( .001); incidence rates of CKD and CLD decreased significantly over time ( .001). Unadjusted incidence rates of DM increased over time ( .01), but remained stable in the adjusted model. Incidence rate patterns for CVD and COPD/asthma were stable over the study period. Population-level increases in incidence rates for HTN, and decreases for CLD and CKD, were observed among PLWH on modern (pre-integrase-inhibitor) HAART from 2000 to 2012. Overall, the increasing incidence of several of these chronic comorbidities in our study suggests that further efforts are needed to maximize the potential for healthy aging among PLWH receiving modern (pre-integrase-inhibitor) HAART.
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http://dx.doi.org/10.1080/03007995.2019.1645999DOI Listing
November 2019

Effectiveness of Ledipasvir/Sofosbuvir and Sofosbuvir/Velpatasvir in People Who Inject Drugs and/or Those in Opioid Agonist Therapy.

Hepatol Commun 2019 Apr 10;3(4):478-492. Epub 2019 Jan 10.

British Columbia Centre for Disease Control Vancouver Canada.

We evaluated the effectiveness of ledipasvir/sofosbuvir (LDV/SOF) in treating hepatitis C virus (HCV) genotype 1 and SOF/velpatasvir (SOF/VEL) for all genotypes among people who inject drugs (PWID) and those not injecting drugs and who were on or off opioid agonist therapy (OAT). Study participants comprised a population-based cohort in British Columbia, Canada. The British Columbia Hepatitis Testers Cohort includes data on individuals tested for HCV from 1990 to 2016 that are integrated with medical visits, hospitalization, and prescription drug data. We classified study participants as off OAT/recent injection drug use (off-OAT/RIDU), off OAT/past IDU (off-OAT/PIDU), off OAT/no IDU (off-OAT/NIDU), on OAT/IDU (on-OAT/IDU), and on OAT/no IDU (on-OAT/NIDU). We assessed sustained virologic response (SVR) 10 weeks after HCV treatment among study groups treated with LDV/SOF or SOF/VEL until January 13, 2018. Analysis included 5,283 eligible participants: 390 off-OAT/RIDU, 598 off-OAT/PIDU, 3,515 off-OAT/NIDU, 609 on-OAT/IDU, and 171 on-OAT/NIDU. The majority were male patients (64%-74%) and aged ≥50 years (58%-85%). The SVRs for off-OAT/RIDU, off-OAT/PIDU, off-OAT/NIDU, on-OAT/IDU, and on-OAT/NIDU were 91% (355/390), 95% (570/598), 96% (3,360/3,515), 93% (567/609), and 95% (163/171), respectively. Among those with no SVR, 14 individuals died while on treatment or before SVR assessment, including 4 from illicit drug overdose. In the overall multivariable model, off-OAT/RIDU, on-OAT/IDU, male sex, cirrhosis, treatment duration <8 weeks, treatment duration 8 weeks, and treatment with SOF/VEL were associated with not achieving SVR. In this large real-world cohort, PWID and/or those on OAT achieved high SVRs, although slightly lower than people not injecting drugs. This finding also highlights the need for additional measures to prevent loss to follow-up and overdose-related deaths among PWID.
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http://dx.doi.org/10.1002/hep4.1307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6442698PMC
April 2019

Factors associated with delayed and late ART initiation among people living with HIV in BC: results from the engage study.

AIDS Care 2019 07 22;31(7):885-892. Epub 2018 Nov 22.

a Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS , St. Paul's Hospital , Vancouver , British Columbia , Canada.

We examined correlates of late and delayed initiation of antiretroviral therapy (ART) in British Columbia, Canada. From December 2013 to December 2015 we recruited treatment-naïve people living with HIV who initiated ART within the previous year. 'Late initiation' was defined as CD4 cell count ≤500 cells/µL at ART initiation and 'delayed initiation' as ≥1 year between HIV diagnosis and initiation. Multivariable logistic regression assessed independent correlates of late and delayed initiation. Of 87 participants, 44 (51%) initiated late and 22 (26%) delayed initiation. Delayed initiation was positively associated with older age (adjusted odds ratio [AOR]: 1.06 per year, 95% confidence interval [95% CI]: 1.01-1.12) and inversely associated with wanting to start ART at diagnosis (AOR: 0.06, 95% CI: 0.02-0.21). Variables associated with late initiation were older age (AOR: 1.09 per year, 95% CI: 1.03-1.15) and medical reason(s) for initiation (AOR: 5.00, 95% CI: 1.41-17.86). Late initiation was less likely among those with greater perceived ART efficacy (AOR 0.94, 95% CI: 0.90-0.98) and history of incarceration (AOR: 0.12, 95% CI: 0.03-0.56). Disparities in timing of initiation were observed for age, perceived ART efficacy, and history of incarceration. Enhanced health services that address these factors may facilitate earlier treatment initiation.
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http://dx.doi.org/10.1080/09540121.2018.1549722DOI Listing
July 2019

The Need and Desire for Mental Health and Substance Use-Related Services Among Clients of Publicly Funded Sexually Transmitted Infection Clinics in Vancouver, Canada.

J Public Health Manag Pract 2019 May/Jun;25(3):E1-E10

School of Population and Public Health (Drs Salway, Shoveller, Dove, Wong, and Gilbert and Ms Rich), School of Nursing (Dr Ferlatte), and Department of Medicine (Dr Grennan), The University of British Columbia, Vancouver, British Columbia, Canada; British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada (Drs Salway, Grennan, Consolacion, Dove, Samji, Wong, and Gilbert, Mr Mirau, and Ms Holgerson); Health Initiative for Men, Vancouver, British Columbia, Canada (Mr Purdie); Division of Infectious Diseases, St Michael's Hospital, Toronto, Ontario, Canada (Dr Tan); Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada (Dr Samji); and TransFocus Consulting, Vancouver, British Columbia, Canada (Mr Scott). Mr Blackwell is an independent consultant in Vancouver, British Columbia, Canada.

Context: Sexually transmitted infections (STI) and mental health and substance use (MHSU) disorders all occur at elevated rates in sexual and gender minorities. These overlapping epidemics, or syndemics, are exacerbated by challenges these same populations face in accessing sexual/gender minority-affirming services. Many publicly funded STI clinics are a low barrier and provide sexual minority-competent care. These sites therefore may be uniquely situated to address clients' MHSU-related needs.

Objective: We characterize the need and desire for MHSU services among STI clinic clients.

Design, Setting, Participants: We conducted a waiting room survey at 6 STI clinics in Metro Vancouver, Canada.

Main Outcome Measures: We calculated the proportion of clients with self-reported unmet MHSU needs in the previous 12 months and, among these clients, barriers to accessing MHSU services and desire for MHSU services within the STI clinic. We also examined social disparities in barriers to accessing MHSU services.

Results: Among 1115 respondents-65% of whom were sexual minorities-39% reported a recent need for MHSU-related care, most frequently in relation to anxiety (29%), depression (26%), substance use (10%), or suicide ideation (7%). Seventy-two percent of this group had not yet talked to a provider about their concern. Common barriers included shame (26%) and inability to afford the service (24%). Eighty-three percent of clients with unmet MHSU needs indicated that they were comfortable discussing MHSU concerns with an STI clinic provider, and 94% expressed desire to receive MHSU assessments, referrals, or counseling in the STI clinic. Sexual and gender minorities and those attending a suburban clinic were more likely to report barriers to accessing MHSU services.

Conclusions: More than a quarter of STI clinic clients report unmet MHSU health care needs; moreover, these clients report high levels of comfort with and desire to discuss MHSU concerns with STI clinic providers. Sexually transmitted infections clinics are thus opportune sites for syndemic service integration.
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http://dx.doi.org/10.1097/PHH.0000000000000904DOI Listing
April 2020

Effect of opioid-substitution therapy and mental health counseling on HIV risk among hepatitis C-infected individuals.

Clin Epidemiol 2018 31;10:1127-1145. Epub 2018 Aug 31.

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

Background: Understanding differences in HIV incidence among people living with hepatitis C virus (HCV) can help inform strategies to prevent HIV infection. We estimated the time to HIV diagnosis among HCV-positive individuals and evaluated factors that could affect HIV-infection risk in this population.

Patients And Methods: The British Columbia Hepatitis Testers Cohort includes all BC residents (~1.5 million: about a third of all residents) tested for HCV and HIV from 1990 to 2013 and is linked to administrative health care and mortality data. All HCV-positive and HIV-negative individuals were followed to measure time to HIV acquisition (positive test) and identify factors associated with HIV acquisition. Adjusted HRs (aHRs) were estimated using Cox proportional-hazard regression.

Results: Of 36,077 HCV-positive individuals, 2,169 (6%) acquired HIV over 266,883 years of follow-up (overall incidence of 8.1 per 1,000 person years). Overall median (IQR) time to HIV infection was 3.87 (6.06) years. In Cox regression, injection-drug use (aHR 1.47, 95% CI 1.33-1.63), HBV infection (aHR 1.34, 95% CI 1.16-1.55), and being a man who has sex with men (aHR 2.78, 95% CI 2.14-3.61) were associated with higher risk of HIV infection. Opioid-substitution therapy (OST) (aHR 0.59, 95% CI 0.52-0.67) and mental health counseling (aHR 0.48, 95% CI 0.43-0.53) were associated with lower risk of HIV infection.

Conclusion: Injection-drug use, HBV coinfection, and being a man who has sex with men were associated with increased HIV risk and engagement in OST and mental health counseling were associated with reduced HIV risk among HCV-positive individuals. Improving access to OST and mental health services could prevent transmission of HIV and other blood-borne infections, especially in settings where access is limited.
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http://dx.doi.org/10.2147/CLEP.S173449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6124790PMC
August 2018

Estimating the impact of early hepatitis C virus clearance on hepatocellular carcinoma risk.

J Viral Hepat 2018 12 28;25(12):1481-1492. Epub 2018 Aug 28.

British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.

Although achieving sustained virological response (SVR) through antiviral therapy could reduce the risk of hepatocellular carcinoma (HCC) attributable to hepatitis C virus (HCV) infection, the impact of early viral clearance on HCC is not well defined. In this study, we compared the risk of HCC among individuals who spontaneously cleared HCV (SC), the referent population, with the risk in untreated chronic HCV (UCHC), those achieved SVR, and those who failed interferon-based treatment (TF). The BC Hepatitis Testers Cohort (BC-HTC) includes individuals tested for HCV between 1990-2013, integrated with medical visits, hospitalizations, cancers, prescription drugs and mortality data. This analysis included all HCV-positive patients with at least one valid HCV RNA by PCR on or after HCV diagnosis. Of 46 666 HCV-infected individuals, there were 12 527 (26.8%) SC; 24 794 (53.1%) UCHC; 5355 (11.5%) SVR and 3990 (8.5%) TF. HCC incidence was lowest (0.3/1000 person-years (PY)) in the SC group and highest in the TF group (7.7/1000 PY). In a multivariable model, compared to SC, TF had the highest HCC risk (hazard ratio (HR):14.52, 95% confidence interval (CI): 9.83-21.47), followed by UCHC (HR: 5.85; 95% CI: 4.07-8.41). Earlier treatment-based viral clearance similar to SC could decrease HCC incidence by 69.4% (95% CI: 57.5-78.0), 30% (95% CI: 10.8-45.1) and 77.5% (95% CI: 69.4-83.5) among UCHC, SVR and TF patients, respectively. In conclusion, using SC as a real-world comparator group, it showed that substantial reduction in HCC risk could be achieved with earlier treatment initiation. These analyses should be replicated in patients who have been treated with direct acting antiviral therapies.
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http://dx.doi.org/10.1111/jvh.12977DOI Listing
December 2018

Identifying injection drug use and estimating population size of people who inject drugs using healthcare administrative datasets.

Int J Drug Policy 2018 05 23;55:31-39. Epub 2018 Feb 23.

British Columbia Centre for Disease Control, Vancouver, BC, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.

Background: Large linked healthcare administrative datasets could be used to monitor programs providing prevention and treatment services to people who inject drugs (PWID). However, diagnostic codes in administrative datasets do not differentiate non-injection from injection drug use (IDU). We validated algorithms based on diagnostic codes and prescription records representing IDU in administrative datasets against interview-based IDU data.

Methods: The British Columbia Hepatitis Testers Cohort (BC-HTC) includes ∼1.7 million individuals tested for HCV/HIV or reported HBV/HCV/HIV/tuberculosis cases in BC from 1990 to 2015, linked to administrative datasets including physician visit, hospitalization and prescription drug records. IDU, assessed through interviews as part of enhanced surveillance at the time of HIV or HCV/HBV diagnosis from a subset of cases included in the BC-HTC (n = 6559), was used as the gold standard. ICD-9/ICD-10 codes for IDU and injecting-related infections (IRI) were grouped with records of opioid substitution therapy (OST) into multiple IDU algorithms in administrative datasets. We assessed the performance of IDU algorithms through calculation of sensitivity, specificity, positive predictive, and negative predictive values.

Results: Sensitivity was highest (90-94%), and specificity was lowest (42-73%) for algorithms based either on IDU or IRI and drug misuse codes. Algorithms requiring both drug misuse and IRI had lower sensitivity (57-60%) and higher specificity (90-92%). An optimal sensitivity and specificity combination was found with two medical visits or a single hospitalization for injectable drugs with (83%/82%) and without OST (78%/83%), respectively. Based on algorithms that included two medical visits, a single hospitalization or OST records, there were 41,358 (1.2% of 11-65 years individuals in BC) recent PWID in BC based on health encounters during 3- year period (2013-2015).

Conclusion: Algorithms for identifying PWID using diagnostic codes in linked administrative data could be used for tracking the progress of programing aimed at PWID. With population-based datasets, this tool can be used to inform much needed estimates of PWID population size.
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http://dx.doi.org/10.1016/j.drugpo.2018.02.001DOI Listing
May 2018

Identifying injection drug use and estimating population size of people who inject drugs using healthcare administrative datasets.

Int J Drug Policy 2018 05 23;55:31-39. Epub 2018 Feb 23.

British Columbia Centre for Disease Control, Vancouver, BC, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.

Background: Large linked healthcare administrative datasets could be used to monitor programs providing prevention and treatment services to people who inject drugs (PWID). However, diagnostic codes in administrative datasets do not differentiate non-injection from injection drug use (IDU). We validated algorithms based on diagnostic codes and prescription records representing IDU in administrative datasets against interview-based IDU data.

Methods: The British Columbia Hepatitis Testers Cohort (BC-HTC) includes ∼1.7 million individuals tested for HCV/HIV or reported HBV/HCV/HIV/tuberculosis cases in BC from 1990 to 2015, linked to administrative datasets including physician visit, hospitalization and prescription drug records. IDU, assessed through interviews as part of enhanced surveillance at the time of HIV or HCV/HBV diagnosis from a subset of cases included in the BC-HTC (n = 6559), was used as the gold standard. ICD-9/ICD-10 codes for IDU and injecting-related infections (IRI) were grouped with records of opioid substitution therapy (OST) into multiple IDU algorithms in administrative datasets. We assessed the performance of IDU algorithms through calculation of sensitivity, specificity, positive predictive, and negative predictive values.

Results: Sensitivity was highest (90-94%), and specificity was lowest (42-73%) for algorithms based either on IDU or IRI and drug misuse codes. Algorithms requiring both drug misuse and IRI had lower sensitivity (57-60%) and higher specificity (90-92%). An optimal sensitivity and specificity combination was found with two medical visits or a single hospitalization for injectable drugs with (83%/82%) and without OST (78%/83%), respectively. Based on algorithms that included two medical visits, a single hospitalization or OST records, there were 41,358 (1.2% of 11-65 years individuals in BC) recent PWID in BC based on health encounters during 3- year period (2013-2015).

Conclusion: Algorithms for identifying PWID using diagnostic codes in linked administrative data could be used for tracking the progress of programing aimed at PWID. With population-based datasets, this tool can be used to inform much needed estimates of PWID population size.
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http://dx.doi.org/10.1016/j.drugpo.2018.02.001DOI Listing
May 2018

Cohort profile: the Comparative Outcomes And Service Utilization Trends (COAST) Study among people living with and without HIV in British Columbia, Canada.

BMJ Open 2018 01 13;8(1):e019115. Epub 2018 Jan 13.

British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.

Purpose: The Comparative Outcomes And Service Utilization Trends (COAST) Study in British Columbia (BC), Canada, was designed to evaluate the determinants of health outcomes and health care services use among people living with HIV (PLHIV) as they age in the period following the introduction of combination antiretroviral therapy (cART). The study also assesses how age-associated comorbidities and health care use among PLHIV may differ from those observed in the general population.

Participants: COAST was established through a data linkage between two provincial data sources: The BC Centre for Excellence in HIV/AIDS Drug Treatment Program, which centrally manages cART dispensation across BC and contains prospectively collected data on demographic, immunological, virological, cART use and other clinical information for all known PLHIV in BC; and Population Data BC, a provincial data repository that holds individual event-level, longitudinal data for all 4.6 million BC residents. COAST participants include 13 907 HIV-positive adults (≥19 years of age) and a 10% random sample inclusive of 516 340 adults from the general population followed from 1996 to 2013.

Findings To Date: For all participants, linked individual-level data include information on demographics, health service use (eg, inpatient care, outpatient care and prescription medication dispensations), mortality, and HIV diagnostic and clinical data. Publications from COAST have demonstrated the significant mortality reductions and dramatic changes in the causes of death among PLHIV from 1996 to 2012, differences in the amount of time spent in a healthy state by HIV status, and high levels of injury and mood disorder diagnosis among PLHIV compared with the general population.

Future Plans: To capture the dynamic nature of population health parameters, regular data updates and a refresh of the data linkage are planned to occur every 2 years, providing the basis for planned analysis to examine age-associated comorbidities and patterns of health service use over time.
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http://dx.doi.org/10.1136/bmjopen-2017-019115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5781099PMC
January 2018

Multimorbidity Among Persons Living with Human Immunodeficiency Virus in the United States.

Clin Infect Dis 2018 04;66(8):1230-1238

Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland.

Background: Age-associated conditions are increasingly common among persons living with human immunodeficiency virus (HIV) (PLWH). A longitudinal investigation of their accrual is needed given their implications on clinical care complexity. We examined trends in the co-occurrence of age-associated conditions among PLWH receiving clinical care, and differences in their prevalence by demographic subgroup.

Methods: This cohort study was nested within the North American AIDS Cohort Collaboration on Research and Design. Participants from HIV outpatient clinics were antiretroviral therapy-exposed PLWH receiving clinical care (ie, ≥1 CD4 count) in the United States during 2000-2009. Multimorbidity was irreversible, defined as having ≥2: hypertension, diabetes mellitus, chronic kidney disease, hypercholesterolemia, end-stage liver disease, or non-AIDS-related cancer. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) comparing demographic subgroups were obtained by Poisson regression with robust error variance, using generalized estimating equations for repeated measures.

Results: Among 22969 adults, 79% were male, 36% were black, and the median baseline age was 40 years (interquartile range, 34-46 years). Between 2000 and 2009, multimorbidity prevalence increased from 8.2% to 22.4% (Ptrend < .001). Adjusting for age, this trend was still significant (P < .001). There was no difference by sex, but blacks were less likely than whites to have multimorbidity (aPR, 0.87; 95% CI, .77-.99). Multimorbidity was the highest among heterosexuals, relative to men who have sex with men (aPR, 1.16; 95% CI, 1.01-1.34). Hypertension and hypercholesterolemia most commonly co-occurred.

Conclusions: Multimorbidity prevalence has increased among PLWH. Comorbidity prevention and multisubspecialty management of increasingly complex healthcare needs will be vital to ensuring that they receive needed care.
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http://dx.doi.org/10.1093/cid/cix998DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5889007PMC
April 2018

A syndemic approach to assess the effect of substance use and social disparities on the evolution of HIV/HCV infections in British Columbia.

PLoS One 2017 22;12(8):e0183609. Epub 2017 Aug 22.

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

Background: Co-occurrence of social conditions and infections may affect HIV/HCV disease risk and progression. We examined the changes in relationship of these social conditions and infections on HIV and hepatitis C virus (HCV) infections over time in British Columbia during 1990-2013.

Methods: The BC Hepatitis Testers Cohort (BC-HTC) includes ~1.5 million individuals tested for HIV or HCV, or reported as a case of HCV, HIV, HBV, or tuberculosis linked to administrative healthcare databases. We classified HCV and HIV infection status into five combinations: HIV-/HCV-, HIV+monoinfected, HIV-/HCV+seroconverters, HIV-/HCV+prevalent, and HIV+/HCV+.

Results: Of 1.37 million eligible individuals, 4.1% were HIV-/HCV+prevalent, 0.5% HIV+monoinfected, 0.3% HIV+/HCV+ co-infected and 0.5% HIV-/HCV+seroconverters. Overall, HIV+monoinfected individuals lived in urban areas (92%), had low injection drug use (IDU) (4%), problematic alcohol use (4%) and were materially more privileged than other groups. HIV+/HCV+ co-infected and HIV-/HCV+seroconverters were materially most deprived (37%, 32%), had higher IDU (28%, 49%), problematic alcohol use (14%, 17%) and major mental illnesses (12%, 21%). IDU, opioid substitution therapy, and material deprivation increased in HIV-/HCV+seroconverters over time. In multivariable multinomial regression models, over time, the odds of IDU declined among HIV-/HCV+prevalent and HIV+monoinfected individuals but not in HIV-/HCV+seroconverters. Declines in odds of problematic alcohol use were observed in HIV-/HCV+seroconverters and coinfected individuals over time.

Conclusions: These results highlight need for designing prevention, care and support services for HIV and HCV infected populations based on the evolving syndemics of infections and social conditions which vary across groups.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0183609PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5568727PMC
October 2017

Late hepatitis B and C diagnosis in relation to disease decompensation and hepatocellular carcinoma development.

J Hepatol 2017 11 4;67(5):909-917. Epub 2017 Jul 4.

BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, British Columbia V5Z 4R4, Canada; University of British Columbia, 2329 West Mall, Vancouver, British Columbia V6T 1Z4, Canada. Electronic address:

Background & Aims: We measured the timing of hepatitis B virus (HBV) and hepatitis C virus (HCV) diagnoses relative to the detection of decompensated cirrhosis (DC) and hepatocellular carcinoma (HCC) as an indicator of late hepatitis diagnosis.

Methods: HBV and HCV diagnoses were defined relative to the diagnosis of DC or HCC such that HBV/HCV diagnoses within two years prior, at the time of or after HCC or DC diagnosis were considered late. We performed multivariable logistic regression to assess factors associated with late HBV/HCV diagnoses among those with DC or HCC.

Results: From 1990 to 2012, 778/32,664 HBV cases (2.4%) and 3,925/57,866 HCV cases (6.8%) developed DC while 628/32,644 HBV cases (1.9%) and 902/57,866 HCV cases (1.6%) developed HCC. Among HBV and HCV cases with DC, 49% and 40% respectively were late diagnoses, as were 46% and 31% of HBV and HCV cases with HCC, respectively. HBV late diagnosis declined from 100% in 1992 to 11% and 26% in 2011, while HCV late diagnosis declined from 100% in 1992 to 16% and 14% in 2011 for DC and HCC respectively. In multivariable modelling, late HBV diagnosis was associated with mental illness and a fewer number of physician visits in the five years prior to HBV diagnosis. Late HCV diagnosis was also associated with fewer physician visits, while those with illicit drug use were less likely to be diagnosed late.

Conclusions: The proportion of late diagnoses has declined over time. People with better engagement with the healthcare system and with risk activities were diagnosed earlier. Lay summary: Late diagnosis of HBV and HCV represents a missed opportunity to reduce the risk of serious liver disease. Our results identify successes in earlier diagnosis over time using risk-based testing as well as groups that are being missed for screening such as those who do not see a physician regularly and those with serious mental illness.
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http://dx.doi.org/10.1016/j.jhep.2017.06.025DOI Listing
November 2017

Is there a rural/urban gap in the quality of HIV care for treatment-naïve HIV-positive individuals initiating antiretroviral therapy in British Columbia?

AIDS Care 2017 10 4;29(10):1218-1226. Epub 2017 May 4.

a BC Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada.

Rurally located people living with HIV (PLWH) face unique challenges associated with remoteness that may negatively affect their HIV care outcomes. The Programmatic Compliance Score (PCS) has been used previously as a quality of care metric, and is predictive of mortality for treatment-naïve individuals initiating combination antiretroviral therapy (cART). This study looked at whether the rurality of PLWH impacted their PCS. PCS was calculated for PLWH (≥19 years old) initiating cART in British Columbia between 2000 and 2013. Rurality was determined at the time of cART initiation using two methodologies: (1) a categorical postal code method; and (2) the General Practice Rurality Index (GPRI), a score representing an individual's degree of rurality. Ordinal logistic regression modeling was used to assess the relationship between rurality and PCS. Among 4616 PLWH with an evaluable PCS, 176 were classified as rural and 3512 as urban (928 had an unknown postal code). After adjusting for age, sex, hepatitis C status, Indigenous ancestry, and year of cART initiation, categorical rurality was not associated with a worse PCS (adjusted odds ratio (AOR) 1.04; 95% CI: 0.77-1.39). However, an increasing degree of rurality was associated with a worse PCS (AOR (per 10 increase in GPRI) 1.13; 95% CI: 1.06-1.20). Given that a poor PCS has been shown to be predictive of all-cause mortality for individuals initiating cART, strategies to improve access to HIV care for rural individuals should be evaluated.
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http://dx.doi.org/10.1080/09540121.2017.1322678DOI Listing
October 2017
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