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Compulsory drug detention exposure is associated with not receiving antiretroviral treatment among people… Hayashi, Kanna; Ti, Lianping; Avihingsanon, Anchalee; Kaplan, Karyn; Suwannawong, Paisan; Wood, Evan; Montaner, Julio S G; Kerr, Thomas May 6, 2015

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RESEARCH Open AccessCompulsory drug detention exposure isassociated with not receiving antiretroviralwho inject drugs inbeen in compulsory drug detention were more likely to be non-recipients of ART whereas those who accessedHayashi et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:16 DOI 10.1186/s13011-015-0013-6317-2194 Health Sciences Mall, Vancouver, BCV6T 1Z3, CanadaFull list of author information is available at the end of the articlepeer-based healthcare-related services were more likely to receive ART. These findings suggest a potentially adverseimpact of compulsory drug detention and highlight the need to expand interventions to facilitate access to ARTamong HIV-positive PWID in this setting.Keywords: ART, Injection drug use, Compulsory drug detention, Peer-based intervention, Thailand* Correspondence: khayashi@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street,Vancouver, BCV6Z 1Y6, Canada2Department of Medicine, Faculty of Medicine, University of British Columbia,time of interview. Daily midazolam injectors, those witBangkok, Thailand: a cross-sectional studyKanna Hayashi1,2*, Lianping Ti1,3, Anchalee Avihingsanon4,5, Karyn Kaplan6, Paisan Suwannawong6, Evan Wood1,2,Julio S G Montaner1,2 and Thomas Kerr1,2AbstractBackground: Thailand has experienced a longstanding epidemic of HIV among people who inject drugs (PWID).However, antiretroviral treatment (ART) coverage among HIV-positive PWID has historically remained low. Whileongoing drug law enforcement involving periodic police crackdowns is known to increase the risk of HIV transmissionamong Thai PWID, the impact of such drug policy approaches on the ART uptake has been understudied. Therefore,we sought to identify factors associated with not receiving ART among HIV-positive PWID in Bangkok, Thailand, with afocus on factors pertaining to drug law enforcement.Methods: Data were collected from a community-recruited sample of HIV-positive PWID in Bangkok who participatedin the Mitsampan Community Research Project between June 2009 and October 2011. We identified factors associatedwith not receiving ART at the time of interview using multivariate logistic regression.Results: In total, 128 HIV-positive PWID participated in this study, with 58 (45.3%) reporting not receiving ART at thetime of interview. In multivariate analyses, completing less than secondary education (adjusted odds ratio [AOR]: 3.32 ;95% confidence interval [CI]: 1.48 – 7.45), daily midazolam injection (AOR: 3.22, 95% CI: 1.45 – 7.15) and exposure tocompulsory drug detention (AOR: 3.36, 95% CI: 1.01 – 11.21) were independently and positively associated with notreceiving ART. Accessing peer-based healthcare information or support services was independently andpositively associated with receiving ART (AOR: 0.21, 95% CI: 0.05 – 0.84).Conclusions: Approximately half of our study group of HIV-positive PWID reported not receiving ART at theh lower education attainment, and individuals who hadtreatment among people© 2015 Hayashi et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.Hayashi et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:16 Page 2 of 8BackgroundIn many parts of the world, people who inject drugs(PWID) are severely affected by HIV/AIDS [1]. It is esti-mated that injection drug use accounts for more thanone-quarter of new HIV infections outside of sub-SaharanAfrica [2]. Injection drug use-driven HIV epidemics areparticularly salient in Asia, which accommodates seven ofthe 15 countries worldwide where >100,000 PWID resideand where an estimated HIV prevalence among PWIDis >10% [3]. Although antiretroviral treatment (ART) hasdramatically reduced HIV-related morbidity and mortal-ity [4,5], and has recently been shown to prevent HIVtransmission [6], access to ART is disproportionatelylow among PWID in many settings [7].Recent reviews have suggested various factors constrain-ing access to ART among PWID worldwide, including in-dividual (e.g., ongoing drug use), social (e.g., stigma), andstructural factors (e.g., incarceration) [8,9]. In particular,barriers stemming from punitive drug policies have drawnincreasing attention [8,9]. Although recent internationalresearch has elucidated the adverse effects of incarcerationon access and adherence to ART [8,10], other impacts as-sociated with the criminalization of drug use have notbeen fully investigated. In particular, some Asian coun-tries, including Thailand, continue to operate systems ofcompulsory drug detention [11-13], despite twelve UnitedNations agencies calling on governments to abolish suchsystems due to the associated human rights violations andsubstandard addiction treatment [14]. In Thailand, thenumber of people who use drugs detained amounted tomore than 102,000 in 2011 [15].Thailand has experienced a longstanding HIV epidemicamong PWID, with an estimated HIV prevalence in thispopulation ranging between 30–50% for more than twodecades [16,17]. Since 2000, Thailand has developed a na-tional initiative to provide ART for free or at a reducedcost [18]. As a result, in 2011, 65% of eligible people livingwith HIV (PLHIV) reportedly received ART, which standsas a relatively high level of coverage for a middle-incomecountry [17,19]. In contrast, only 2 per 100 HIV-positivePWID were estimated to have ever accessed ART inThailand in 2007 [7], although in our 2009 study, 45% of67 HIV-positive PWID in Bangkok reported receivingART at the time of interview [20].The Thai government has for many years implementeddrug prohibition approaches involving periodic policecrackdowns [21]. While some potentially effective measuresto improve access to ART among HIV-positive PWID existin this setting, including methadone treatment and peer-support groups [8], few studies have investigated factorsthat promote or undermine uptake of ART among PWIDwithin a context of drug law enforcement involving peri-odic police crackdowns. Therefore, we sought to iden-tify factors associated with not receiving ART amonga community-recruited sample of HIV-positive PWID inBangkok, Thailand, with a focus on factors pertaining todrug law enforcement.MethodsStudy sampleData were derived from the Mitsampan CommunityResearch Project, a collaborative research effort involvingthe Mitsampan Harm Reduction Center (MSHRC; a druguser-run drop-in centre in Bangkok, Thailand), Thai AIDSTreatment Action Group (Bangkok, Thailand), ChulalongkornUniversity (Bangkok, Thailand), and the British ColumbiaCentre for Excellence in HIV/AIDS/University of BritishColumbia (Vancouver, Canada). This serial cross-sectionalstudy aims to investigate drug-using behaviour, healthcareaccess, and other drug-related harms among PWID inBangkok. Between June 2009 and October 2011, theresearch partners undertook two waves of surveying,which involved an accumulated total of 757 community-recruited PWID in Bangkok. Potential participants wererecruited through peer outreach efforts and word-of-mouth, and were invited to attend the MSHRC or O-ZoneHouse (another drop-in centre in Bangkok) in order tobe part of the study. Recruitment criteria included adultsresiding in Bangkok or in adjacent provinces who hadinjected drug(s) in the past six months. All participants pro-vided informed consent and completed an interviewer-administered questionnaire eliciting a range of information,including demographic characteristics, drug use patterns,HIV serostatus, and experiences with drug law enforce-ment and accessing healthcare. Upon completion of thequestionnaire, participants received a stipend of 350 ThaiBaht (approximately US$12). The study was approved bythe research ethics boards at Chulalongkorn University(COA No. 085/2009, 093/2011) and the University of BritishColumbia (H08-00702, H11-00581).All participants who completed the interview in 2009or 2011 and reported being HIV-positive were eligiblefor inclusion in this study. Given that some individualswere interviewed in both 2009 and 2011, we included allparticipants from the first wave and only new participantsfrom the second wave in order to ensure the independenceof the observations analyzed in this study. The sample ofeach survey wave was further restricted to individuals whohad complete data for the present analyses.Variable selectionThe primary outcome of interest was not receiving ARTat the time of interview, defined as answering “No” tothe following question: “Are you currently taking antire-trovirals (ARVs)?” Based on previous literature [8], a setof explanatory variables were hypothesized to be associ-ated with the outcome. Demographic characteristics in-cluded median age (≥38 years vs. < 38 years); gender(female vs. male); and education attainment (< secondaryeducation vs. ≥ secondary education). Indicators for theseverity of substance use included: heroin injection (dailyvs. < daily); methamphetamine injection (daily vs. < daily);midazolam (a short-acting benzodiazepine) injection (dailyvs. < daily); and alcohol consumption (daily vs. < daily).Exposure to drug law enforcement included: ever beatenby police; ever incarcerated; and ever in compulsory drugdetention. Finally, experiences with accessing healthcareincluded: ever accessed methadone treatment; ever receivedhealthcare information or support services at the MSHRC;and reporting barriers to healthcare (any vs. none). As inour previous work [22], our barriers to healthcare variableincluded a range of potential barriers, including but notlimited to: long wait times, poor treatment by healthcareproviders, financial barriers, and transportation issues. Allvariables were coded dichotomously as yes vs. no, unlessotherwise stated. Variables related to drug use referred tothe previous six months.Statistical analysesTo examine bivariate associations between the outcomeand the explanatory variables of interest, we used thePearson X2 test. Fisher’s exact test was used when one ormore of the cells contained expected values less than orequal to five. Three variables (i.e., methamphetamine in-jection, alcohol consumption, and ever incarcerated) metthis criterion. Next, we used an a priori-defined statisticalprotocol that examined factors associated with the out-come by fitting a multivariate logistic regression modelthat included all variables that were significantly associ-ated with the outcome at the p < 0.05 level in bivariateanalyses. All p-values were two-sided. All statisticalanalyses were performed using SAS software version9.3 (SAS, Cary, NC).ResultsFigure 1 describes the determination of the analytic sam-ple. As shown, 133 (20.5%) of 650 unique individuals whoHayashi et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:16 Page 3 of 8Figure 1 Determination of the analytic sample.Hayashi et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:16 Page 4 of 8completed the interview over the two waves of surveyingin 2009 and 2011 identified themselves as being HIV-positive. Among the remaining 517 participants who didnot report being HIV-positive, 336 (65.0%) reportedhaving been tested for HIV in the previous six months. Ofthe 133 HIV-positive participants, 5 (3.8%) were excludedfrom the present analysis due to incomplete data. There-fore, a total of 128 HIV-positive participants were eligiblefor the present study.Among 128 HIV-positive PWID participated in thisstudy, 25 (19.5%) were women, and the median age was38 years (interquartile range: 34 – 44 years). In total, 58(45.3%) individuals reported not receiving ART at thetime of interview. Of these, 36 (62.1%) reported havingnot seen an HIV doctor on a regular basis (i.e., at leastonce in six months).Table 1 shows the summary statistics of the sample andthe results of bivariate analyses. As shown, in bivariate ana-lyses, completing less than secondary education (odds ratio[OR]: 3.54; 95% confidence interval [CI]: 1.70 – 7.39), dailymidazolam injection in the previous six months (OR: 3.64;95% CI: 1.75 – 7.58) and having ever been in compulsorydrug detention (OR: 3.08; 95% CI: 1.09 – 8.72) were signifi-cantly and positively associated with not receiving ART.Having ever received healthcare information or supportservices at the MSHRC was significantly and negatively as-sociated with not receiving ART (OR: 0.22; 95% CI: 0.06 –0.80).Table 2 shows the results of the multivariate analysis.As shown, completing less than secondary education(adjusted odds ratio [AOR]: 3.32; 95% CI: 1.48 – 7.45),daily midazolam injection (AOR: 3.22; 95% CI: 1.45 –7.15) and having ever been in compulsory drug detention(AOR: 3.36; 95% CI: 1.01 – 11.21) remained independentlyand positively associated with not receiving ART. Havingever received healthcare information or support servicesat the MSHRC also remained independently and nega-tively associated with the outcome (AOR: 0.21; 95% CI:0.05 – 0.84).DiscussionWe found that approximately half of our study group ofHIV-positive PWID in Bangkok reported not receivingART. Because blood specimens were not collected, wewere unable to assess the indication for ART initiation(e.g., CD4 counts <350 cells/mm3 according to the 2010Thai national guidelines for ART [19]) among those notreceiving ART at the time of interview. However, themajority of Thai PLHIV have been shown to be diag-nosed with HIV infection at a late stage of HIV disease,with approximately 60% starting ART with CD4 levelsof <100 cells per cubic millimeter [17], and therefore asubstantial portion of our sample of untreated HIV-positivePWID may have met ART eligibility criteria. Futureresearch should investigate stages of HIV disease amongHIV-positive PWID who are not receiving ART. Nonethe-less, given the persistently high prevalence of syringe shar-ing among HIV-positive PWID in this setting [17,20,23],and the now widely recognized impact of HIV treatmenton the prevention of new HIV infections [24], ensuring ac-cess to ARTamong PWID remains a high priority in Thai-land’s response to the HIV epidemic [17]. In this regard,our findings provide important insights into barriers toand facilitators of ART access among HIV-positive PWIDin Bangkok. In addition, we note that evolving ART guide-lines have dramatically increased the proportion of PLHIVin need of ART, particularly among high-risk populationsmarked with significant comorbidities, including PWID,as the Joint United Nations Programme on HIV/AIDS hasrecently estimated that approximately 85% of PLHIV areeligible for ART provision under the 2013 World HealthOrganization criteria [25]. Furthermore, beginning inOctober 2014, the Thai national ART guidelines has re-moved CD4 count from the ART eligibility criteria, andnow all PLHIV in Thailand are eligible for ART initiationregardless of CD4 count [23].Of particular concern is the independent associationbetween exposure to compulsory drug detention and notreceiving ART. In Thailand, it has been reported thatsome public hospitals collect and share informationabout individual drug use with police [26]. Given the pu-nitive nature of compulsory drug detention centres [21],our findings may suggest that HIV-positive PWID whohave been detained in such centres are reluctant to ac-cess HIV treatment due to fear of disclosing their druguse to healthcare providers and thereby risk being re-admitted to detention centres. Consistent with our inter-pretation, a recent study also found an independentrelationship between exposure to compulsory drug de-tention and the avoidance of healthcare among PWID inthis setting [21]. Furthermore, a previous report alsosuggested inconsistent availability of ART across the cus-todial settings as well as a lack of continuity of health-care, including ART, on entry to and on release fromdetention in Thailand [26]. These findings suggest thatcompulsory drug detention may be placing an undueburden on public health by undermining ex-detainees’access to HIV treatment. Future research should longitu-dinally assess the impact of compulsory drug detentionexposure on HIV disease progression in this setting.The finding that HIV-positive PWID who accessedpeer-based healthcare information and support serviceswere more likely to be on ART is congruent with a largebody of literature indicating the effectiveness of peer-based interventions in providing HIV/AIDS educationand supporting access to HIV care among PWID [8,27].Our findings that the positive effect of peer-based sup-port services on the ART uptake remained significantTable 1 Bivariate associations with not receiving ART among HIV-positive PWID in Bangkok, Thailand (n = 128)Characteristic Currently on ART Odds ratio (95%CI) p - valueNo 58 (45.3%) Yes 70 (54.7%)DemographicOlder age≥38 years old 30 (51.7%) 35 (50.0%) 1.07 (0.53 – 2.15) 0.846<38 years old 28 (48.3%) 35 (50.0%)GenderFemale 12 (20.7%) 13 (18.6%) 1.14 (0.48 – 2.75) 0.764Male 46 (79.3%) 57 (81.4%)Education attainment< Secondary education 34 (58.6%) 20 (28.6%) 3.54 (1.70 – 7.39) <0.001≥ Secondary education 24 (41.4%) 50 (71.4%)Substance use behaviourHeroin injection*Daily 9 (15.5%) 8 (11.4%) 1.42 (0.51 – 3.96) 0.497< Daily 49 (84.5%) 62 (88.6%)Methamphetamine injection*Daily 7 (12.1%) 3 ( 4.3%) 3.07 (0.65 – 19.10) 0.184†< Daily 51 (87.9%) 67 (95.7%)Midazolam injection*Daily 38 (65.5%) 24 (34.3%) 3.64 (1.75 – 7.58) <0.001< Daily 20 (34.5%) 46 (65.7%)Alcohol consumption*Daily 3 ( 5.3%) 3 ( 4.3%) 1.24 (0.16 – 9.63) >0.999†< Daily 54 (94.7%) 67 (95.7%)Experiences with drug law enforcementEver beaten by policeYes 33 (56.9%) 28 (40.0%) 1.98 (0.98 – 4.01) 0.057No 25 (43.1%) 42 (60.0%)Ever incarceratedYes 56 (96.6%) 63 (90.0%) 3.11 (0.56 – 31.65) 0.182†No 2 ( 3.4%) 7 (10.0%)Ever in compulsory drug detentionYes 13 (22.4%) 6 ( 8.6%) 3.08 (1.09 – 8.72) 0.028No 45 (77.6%) 64 (91.4%)Healthcare accessEver accessed methadone treatmentYes 51 (87.9%) 62 (88.6%) 0.94 (0.32 – 2.77) 0.911No 7 (12.1%) 8 (11.4%)Ever received healthcare information or support services at the MSHRCYes 3 ( 5.2%) 14 (20.0%) 0.22 (0.06 – 0.80) 0.014No 55 (94.8%) 56 (80.0%)Reporting barriers to healthcare*Any 33 (56.9%) 48 (68.6%) 0.61 (0.29 – 1.25) 0.173None 25 (43.1%) 22 (31.4%)PWID: people who inject drugs; ART: antiretroviral treatment; CI: confidence interval; MSHRC: Mitsampan Harm Reduction Center.*denotes activities in the previous 6 months.†Fisher’s exact test was used.Hayashi et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:16 Page 5 of 8ssRCrvaHayashi et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:16 Page 6 of 8even after adjusting for the effect of education attainmentfurther suggest the effectiveness of such peer-based inter-ventions. Since 1992, the Thai Ministry of Public Healthhas supported many PLHIV peer support groups, whichhave been working to facilitate access to HIV treatmentamong PLHIV in the country [28]. However, until re-cently, there have been few PWID-specific PLHIV peersupport services, and those that exist are primarily fundedby international donors [29]. The MSHRC is one of thosefew sites that provide a variety of services via a peer-delivered approach, including sterile syringe distribution,harm reduction education, food and drinks, and supportfor healthcare access [30]. A previous study has shownthat this model has successfully reached sub-populationsof PWID who were particularly vulnerable to HIV infec-tion and other drug-related harm in this setting [30]. Giventhe profound stigma against PWID in healthcare settingsin Thailand [26,31], the expansion of PWID-specific peersupport, such as that offered at the MSHRC, may be cru-cial for facilitating access to ART among HIV-positivePWID in this setting.We also found that daily midazolam injection was inde-Table 2 Multivariate logistic regression analysis of factors ain Bangkok, Thailand (n = 128)CharacteristicEducation attainment(< Secondary education vs. ≥ Secondary education)Midazolam injection*(Daily vs. < Daily)Ever in compulsory drug detention(Yes vs. No)Ever received healthcare information or support services at the MSH(Yes vs. No)PWID: people who inject drugs; ART: antiretroviral treatment; CI: confidence inte*denotes activities in the previous 6 months.pendently associated with not receiving ART. Midazolam isa short-acting benzodiazepine that can be legally obtainedthrough private clinics in Bangkok [32]. While injection ofbenzodiazepines is common among opioid users in manysettings [33,34], in Bangkok, midazolam is the most com-monly injected drug among PWID [22]. Amnesia and severeinjection-related injuries and disease associated with mid-azolam use [22] indicate a need for additional support ser-vices if these daily midazolam injectors are to initiate ART.This study has several limitations. First, we cannotinfer causation from this observational study. Further,the cross-sectional study design did not allow us to as-sess temporal relationships between the outcome andexplanatory variables. Second, due to the lack of HIV-related clinical data (e.g., CD4 counts), we were unableto assess the eligibility for ART among our sample. Whilewe also recognize that it would have been ideal to utilize amore sensitive assessment of untreated HIV infection(e.g., whether a participant was not receiving ART at thetime of interview due to poor adherence, treatment discon-tinuation, or being ineligible for ART, etc.), we were unableto include such measurements in our questionnaire. Futureresearch should seek to use a refined measure of untreatedHIV infection. To this end, an exploratory qualitative studyto understand reasons for not accessing ART would pro-vide useful data for refining the measure and selecting thestudy variables. Third, the self-reported data may havebeen affected by some reporting biases, including sociallydesirable responding and recall bias. For example, thesebiases might have led to the underestimation of the preva-lence of compulsory drug detention exposure (due to so-cially desirable reporting) and ever receiving services at theMSHRC (due to recall bias). However, we believe that it isunlikely that such information biases differentially influ-enced the data by HIV treatment status. We also note thatthis type of self-reported data has been commonly utilizedin observational studies involving PWID and has beenfound to be valid [35]. Lastly, due to the small sample size,there were wide intervals around some of the estimates re-ociated with not receiving ART among HIV-positive PWIDAdjusted odds ratio (95% CI) p-value3.32 (1.48 – 7.45) 0.0043.22 (1.45 – 7.15) 0.0043.36 (1.01 – 11.21) 0.0490.21 (0.05 – 0.84) 0.028l; MSHRC: Mitsampan Harm Reduction Center.ported. Also, as the study sample was not randomly se-lected, our findings may not be generalizable to PWIDpopulations in Thailand or elsewhere.ConclusionsIn summary, we found that about half of our study groupof HIV-positive PWID in Bangkok reported that they werenot receiving ART at the time of interview. Daily midazo-lam injectors, those with lower education attainment, andindividuals who had been in compulsory drug detentionwere more likely to be non-recipients of ART. In contrast,individuals who accessed peer-based healthcare informationand support services were more likely to be on ART. Thesefindings suggest a potentially adverse impact of compulsorydrug detention and indicate a need for expanding interven-tions to facilitate access to ART among HIV-positive PWIDin this setting.Hayashi et al. Substance Abuse Treatment, Prevention, and Policy  (2015) 10:16 Page 7 of 8AbbreviationsART: Antiretroviral treatment; HIV: Human immunodeficiency virus;MSHRC: Mitsampan Harm Reduction Center; PLHIV: People living with HIV;PWID: People who inject drugs.Competing interestsJulio SG Montaner is supported with grants paid to his institution by theBritish Columbia Ministry of Health and by the US National Institutes ofHealth (R01DA036307). He has also received limited unrestricted funding,paid to his institution, from Abbvie, Bristol-Myers Squibb, Gilead Sciences,Janssen, Merck, and ViiV Healthcare. The authors have no other potentialconflicts of interest to disclose.Authors’ contributionsKanna Hayashi and Thomas Kerr designed the study. Kanna Hayashiconducted the statistical analyses, drafted the manuscript and incorporatedsuggestions from all co-authors. All authors made significant contributions tothe conception of the analyses, interpretation of the data, and drafting ofthe manuscript.AcknowledgementsWe would particularly like to thank the staff and volunteers at theMitsampan Harm Reduction Center, Thai AIDS Treatment Action Group andO-Zone House for their support and Dr. Niyada Kiatying-Angsulee of theSocial Research Institute, Chulalongkorn University, for her assistance withdeveloping this project. We also thank Tricia Collingham, Deborah Graham,Caitlin Johnston, Calvin Lai and Peter Vann for their research and administrativeassistance, and Prempreeda Pramoj Na Ayutthaya, Arphatsaporn Chaimongkonand Sattara Hattirat for their assistance with data collection. The study wassupported by Michael Smith Foundation for Health Research. This researchwas also undertaken, in part, thanks to funding from the Canada ResearchChairs program through a Tier 1 Canada Research Chair in Inner City Medicinewhich supports Evan Wood. Kanna Hayashi and Lianping Ti are supported bythe Canadian Institutes of Health Research.Author details1British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street,Vancouver, BCV6Z 1Y6, Canada. 2Department of Medicine, Faculty ofMedicine, University of British Columbia, 317-2194 Health Sciences Mall,Vancouver, BCV6T 1Z3, Canada. 3School of Population and Public Health,University of British Columbia, 2206 East Mall, Vancouver, BCV6T 1Z3Canada.4HIV-NAT, Thai Red Cross AIDS Research Centre, 104 Ratchadamri Rd,Prathumwan, Bangkok 10300, Thailand. 5Department of Medicine, Faculty ofMedicine, Chulalongkorn University, 254 Phayathai Road, Bangkok 10330,Thailand. 6Thai AIDS Treatment Action Group, 18/89 Vipawadee Rd,soi 40Chatuchak, Bangkok 10900, Thailand.Received: 13 December 2014 Accepted: 24 April 2015References1. Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA,et al. 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