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HIV Prevalence among Aboriginal British Columbians Hogg, Robert S; Strathdee, Steffanie; Kerr, Thomas; Wood, Evan; Remis, Robert Dec 24, 2005

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ralssBioMed CentHarm Reduction JournalOpen AcceResearchHIV Prevalence among Aboriginal British ColumbiansRobert S Hogg*1,2,3, Steffanie Strathdee4, Thomas Kerr1, Evan Wood1,2 and Robert Remis5Address: 1BC Centre for Excellence in HIV/AIDS, 2Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada, 3Department of Health Care and Epidemiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada, 4Department of Family and Preventive Medicine, Division of International Health, University of California, San Diego School of Medicine, California and 5Department of Public Health Sciences, Faculty of Medicine, University of Toronto, University of Toronto, CanadaEmail: Robert S Hogg* - bobhogg@cfenet.ubc.ca; Steffanie Strathdee - sstrathdee@ucsd.edu; Thomas Kerr - tkerr@cfenet.ubc.ca; Evan Wood - ewood@cfenet.ubc.ca; Robert Remis - rremis@utoronto.ca* Corresponding author    AbstractContext: There is considerable concern about the spread of HIV disease among Aboriginalpeoples in British Columbia.Objective: To estimate the number of Aboriginal British Columbians infected with HIV.Design and setting: A population-based analysis of Aboriginal men and women in BritishColumbia, Canada from 1980 to 2001.Participants: Epidemic curves were fit for gay and bisexual men, injection drug users, men andwomen aged 15 to 49 years and persons over 50 years of age.Main outcome measures: HIV prevalence for the total Aboriginal population was modeled usingthe UNAIDS/WHO Estimation and Projection Package (EPP). Monte Carlo simulation was used toestimate potential number infected for select transmission group in 2001.Results: A total of 170,025 Aboriginals resided in British Columbia in 2001, of whom 69% were15 years and older. Of these 1,691 (range 1,479 – 1,955) men and women aged 15 years and overwere living with HIV with overall prevalence ranging from 1.26% to 1.66%. The majority of thepersons infected were men. Injection drug users (range 1,202 – 1,744) and gay and bisexual men(range 145, 232) contributed the greatest number of infections. Few persons infected were fromlow risk populations.Conclusion: More than 1 in every 100 Aboriginals aged 15 years and over was living with HIV in2001. Culturally appropriate approaches are needed to tailor effective HIV interventions to thiscommunity.IntroductionAboriginal peoples have resided in British Columbia sincehere through successive migrations across a land bridgespanning the Bering Strait and then arrived here eitherPublished: 24 December 2005Harm Reduction Journal 2005, 2:26 doi:10.1186/1477-7517-2-26Received: 20 May 2005Accepted: 24 December 2005This article is available from: http://www.harmreductionjournal.com/content/2/1/26© 2005 Hogg et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 6(page number not for citation purposes)the end of the last ice age 12,000 years ago [1]. Archaeo-logical evidence suggests that these first peoples arrivedalong the coast [2] or through an interior passage left asthe glacier sheets melted [3]. Three distinct cultural areasHarm Reduction Journal 2005, 2:26 http://www.harmreductionjournal.com/content/2/1/26with many distinct cultures are prominent – the subarticin the Northeast, the plateau in the Southeast, and theNorthwest Coast along the coast from the Queen Char-lottes to the southern most tip of Vancouver Island. Priorto contact with Europeans, populations were quite largeespecially along the coast.Contact with Europeans brought numerous infectious dis-eases that reduced the Aboriginal population in BritishColumbia by nearly two thirds. The total population con-tinued to decrease until the 1920s and have sincerebounded to sizes near pre-contact levels [4,5]. However,high levels of mortality persisted long after European con-tact, mainly due to infectious diseases [4,6]. Initially, dis-ease like smallpox had a devastating affect on populationsize [4]. Later, Aboriginals where inflicted with diseaseslike tuberculosis that were endemic until quite recently[7]. In recent years, there has been increasing concernregarding the spread of HIV disease among Aboriginalpeoples. HIV appears to be concentrated among injectiondrug users and gay and bisexual men [8-11]. Rates of HIVinfection among pregnant women remain low, but are sig-nificantly higher than in the general population[12]. Thepurpose of this paper is to estimate the current number ofAboriginal British Columbians infected with HIV.MethodsOur estimates of HIV prevalence in the British ColumbianAmerican Indians, Métis, and Inuit. Also included arethose that did not self-identify as Aboriginal, but whowere registered under the Indian Act and/or were mem-bers of a band or First Nation [13].HIV prevalence data from at risk populations were used tomodel HIV prevalence trends for adults and to calculatethe number of new infections, AIDS cases and deathsfrom 1980 to 2001. Six adult Aboriginal populationgroups, aged 15 years and over, were modeled – gay andbisexual men, injection drug users in Greater Vancouverand the rest of the province, low-risk men and womenaged 15 to 49 years, and low-risk persons aged 50 yearsand over. Low-risk refers to Aboriginal persons who basedon current seroprevalence studies were less likely toacquire HIV than gay and bisexual men and injection drugusers in this population. Gay and bisexual men were esti-mated to be 3% of the total Aboriginal male population[14]. The total injection drug user population in GreaterVancouver was based on capture-recapture estimates andfor the rest of the province on estimates of clean needledistributed at needle exchanges and proportion of drugover deaths [15,16]. Based on estimates derived from theVancouver Injection Drug Users Study (VIDUS) at leastquarter of these injection drug users are of Aboriginaldescent [8]. The population of injection drug users in theGreater Vancouver region was estimated to be 12,000(95% CI: 10,000 – 15,000) and of similar magnitude out-Table 1: Input assumptions for total population and HIV prevalence for Aboriginal persons ages 15 and over, by scenario and groupCategory/ years Gay and Bisexual menInjection drug users 15–49 years* 50+Year Vancouver Other Men WomenLow growth scenarioPopulation2001 1,600 3,000 3,000 39,400 46,700 24,100HIV Prevalence1986 12.6 1.2 1.2 0 0 01991 14.3 1.7 1.7 0 0 01996 15.0 6.0 2.0* 0 0 02001 19.0 38.0 2.0* 0 0 0High growth scenarioPopulation2001 1,600 4,250 3,250 38,700 45,900 24,100HIV Prevalence1986 12.6 2.3 2.3 0 0 01991 14.3 1.7 1.7 0 0 01996 15.0 6.0 6.0* 0 0 02001 19.0 38.0 6.0* .08 .10 0* Values are assumed. Among 15 to 49 years olds posted rates are a third of published rates.Page 2 of 6(page number not for citation purposes)Aboriginal population were based upon surveillance data.Aboriginals refer to persons who self-identify as – Northside the region as half the needles distributed at needleexchanges and overdose deaths occur outside of GreaterHarm Reduction Journal 2005, 2:26 http://www.harmreductionjournal.com/content/2/1/26Vancouver[16]. In total, there were likely 24,000 injectiondrug users in the province of which 6,000 were Aborigi-nal. Population estimates for low-risk persons aged 15 to49 years and those laged 50 years and over were basedintercensal estimates of Registered Indians produced byBC Vital Statistics and adjusted to the 2001 Census popu-lation of Aboriginals [16].HIV prevalence estimates were obtained from a variety ofserosurveillance and cohort studies. Estimates of HIVprevalence for the gay and bisexual men were obtainedfrom published and unpublished estimates from twocohorts studies (Vancouver Lymphadenopathy AIDSStudy and the Vanguard Study) and adjusted to estimatesreported for the entire gay and bisexual male populationin Vancouver and British Columbia [12,17]. Among injec-tion drug users HIV prevalence estimates were obtainedfrom published cohort and cross sectional studies. Annu-alized estimates of HIV prevalence from 1996 onwardswere obtained from VIDUS[8,18]. Estimates prior to thatdate were obtained from serosurveillance studies of street-based populations and needle exchanges in Vancouverand Victoria[12]. HIV prevalence estimates of low-riskpersons aged 15 to 49 years and 50 years and over werebased on data obtained from pregnant women and menand women in alcohol rehabilitation[12,19,20].Two scenarios were modelled based on varying assump-tions relating to the size of the at-risk population and HIVprevalence (refer to Table 1). The low growth scenarioassumed the at-risk gay and bisexual population to be 3%of the adult male population. The population of Aborigi-nal injection drug user in Greater Vancouver was assumedto be 3,000 or 25% of injection drug users in that region,the point estimate from the capture-recapture study[15].Injection drug user population outside this region wasalso assumed to be 3,000 since half of the overdose deathsand clean needles distributed occur in this region. HIVprevalence in gay and bisexual men was assumed to besimilar to the general gay and bisexual population. Ininjection drug users HIV prevalence was assumed toincrease to 40% in Vancouver and to move-up to no morethan 2% in other areas of the province. HIV prevalence inlow-risk persons aged 15 to 49 years and 50 years and overwas assumed to be zero.The high growth scenario assumed the gay and bisexualmale population to be the same as in the low growth sce-nario. The Greater Vancouver Aboriginal injection druguser population was assumed to be 3,750 persons or 25%of the upper limit of the capture-recapture estimate of15,000 [15]. A total of 500 Aboriginal injection drug usersin Victoria were assumed to have the same HIV prevalenceusers from outside of Vancouver and Victoria, HIV preva-lence was assumed to increase to 6% by 1996 [12]. HIVprevalence in low-risk women aged 15 to 49 years wasassumed to increase to .08 by 2001 or a third of estimatesobtained from studies of pregnant women and women inalcohol rehabilitation. HIV prevalence in low-risk menaged 15–49 was also assumed to increase and the numberof HIV-infected persons aged 50 years and over wasassumed to be zero.HIV prevalence for the total Aboriginal population wasmodeled using the UNAIDS/WHO Estimation and Projec-tion Package (EPP). In EPP, HIV prevalence time trendswere estimated by fitting a simple epidemiological modelto surveillance data[22]. Epidemic curves were fit for gayand bisexual men, injection drug users, men and womenaged 15 to 49 years and persons over 65 years of age. Sep-arate epidemic curves for these groups were then aggre-gated by EPP to find the best fitting curve that describestrends in HIV prevalence in the total adult Aboriginal overtime.Monte Carlo simulation methodology was used to esti-mate potential number infected for select transmissiongroup in 2001. Input parameters for the model were takenfrom our low and high growth scenarios. The injectiondrug user group was collapsed into one category for theseanalyses. A total of 100,000 trials were completed toderive potential ranges in the number of injection drugusers, gay and bisexual men, and low risk women in thepopulation.ResultsA total of 170,025 Aboriginals resided in the province in2001, of whom 69% were 15 years and older. The major-ity of Aboriginals were women (51%). The median age formen and women was 26 and 28 years, respectively. NorthAmerican Indians made-up the largest component of thepopulation at 118,295 (70%), followed by Metis at44,265 (26%), and Inuit at 800 (0.5%). The rest, 6660(4%) were Aboriginals of other or multiple origin. TheGreater Vancouver population was 36,855 with 10,440living in the city. The population was also highly mobilewith 46% of persons who were 5 years and older movingat least once in the past five years.Table 1 outlines the at-risk population and HIV preva-lence assumptions for Scenarios one and two. As outlinedin this table the injection drug users and gay and bisexualmale populations are relatively small in comparison tothe low-risk populations aged 15 and over. In both scenar-ios HIV prevalence is highest in Greater Vancouver injec-tion drug users and second highest among gay andPage 3 of 6(page number not for citation purposes)as in Greater Vancouver and added to the Greater Vancou-ver group[21]. Among the remaining 3,250 injection drugbisexual men.Harm Reduction Journal 2005, 2:26 http://www.harmreductionjournal.com/content/2/1/26Figures 1 characterizes the trends in HIV prevalence in thelow and high growth scenarios since 1980. As note shownhere, HIV prevalence in the Aboriginal population hasincreased notably since 1980.Table 2 provides estimates of prevalence and the numberliving with HIV by gender and transmission group in2001. Estimates were derived from 100,000 Monte Carlosimulation trials, where the input parameters were basedon the figures from the low and high growth scenariosproduced for this study. Based on this analysis, a total of1,691 (range 1,479 – 1,955) men and women were livingwith HIV at the end of 2001. Overall, 1.44% (range1.26%, 1.66%) of the population 15 years and over wasHIV-positive. The majority of the persons infected weremen (55.3% ; range 55.6%, 54.8%). Injection drug users(1,458; range 1,202 – 1,744) and gay and bisexual men(186; range 145, 232) contributed the greatest number ofinfections. Few of the persons living with HIV were fromlow risk populations.DiscussionMore than 1 in every 100 Aboriginal persons aged 15 yearsand over was living with HIV in 2001. Approximately aquarter to a third of all infections among Aboriginal peo-ples in Canada occurred in this province [23]. The rate ofinfection among Aboriginal British Columbians wasapproximately two times the rate for Canadian Aborigi-nals overall. The majority of new infections among Abo-riginals occurred in injection drug users with the majorityof these being concentrated in Greater Vancouver. How-ever, our results point to increasing numbers of injectiondrug users being infected outside Greater Vancouver andconsiderable number of Aboriginal gay and bisexual meninfected with HIV in this province.new infections among injection drug users. In Vancouver,HIV prevalence among Aboriginal injection drug users hasincreased from less than 5% in early 1990s to approxi-mately 40% in 2004 [24]. The prevalence of HIV amongAboriginal injection drug users was considerably higherthan their non-Aboriginal counterparts; and half of theAboriginal drug user population were women, which wasa considerably higher proportion than in the non-Aborig-inal population [8]. Risk factors for HIV acquisitionappear to vary by gender as well. Among women, frequentspeedball (combined cocaine and heroin) injection andgoing on binges of injection drug use were independentpredictors of HIV seroconversion; while among men HIVseroconversion was associated with frequent speedballinjection and cocaine injection [8,18]The acquisition of HIV among Aboriginals was partiallydue to syringe sharing. Needle exchanges in BritishColumbia provide needles, needle cleaning supplies andcondoms to injection drug users and sex trade workers.Although six millions needles are given out annuallythrough this program, needle exchanges provide sterileequipment for only a small percentage of drug injectionepisodes – in Vancouver this was estimated to be as low as10 to 20% [25]. Among injection drug users daily needleexchanges remains modest at approximately 40% at fixedsites and 50% at mobile sites [26]. Even with dailyexchange approximately a third of participants were bor-rowing and lending needles. Although acquiring needlesexclusively from the needle exchange attendance wasindependently associated with less sharing, persistentsharing was associated with difficulty accessing sterile nee-dles, bingeing, and frequent cocaine injection [27].Unprotected sex also played a role in the acquisition ofnew infections. There was considerable variability amonginjection drug users in condom use with sex trade clientsand casual and regular sexual partners [8,18,28]. Based onVIDUS data the vast majority of men and women weresexually active, 72 and 92% respectively in the last sixmonths prior to enrolment. The mean age of first sexualencounter was 15 years for either gender. Life timenumber of sexual partners was also high with over 20% ofmen and 50% of women having more than 100 sexualpartners. Among men and women, condoms were gener-ally not used with regular partners, half the time with cas-ual partners, and 80% of the time with clients. Nine percent of men reported having had sex with a man with con-dom use being 71% for anal intercourse and 60% for oralsex with clients. Among women sex trade workers vaginalintercourse was most common with condom usage being82%. Seventy-five percent of these women used condomsduring oral sex with clients. Aboriginal generally exhibitHIV prevalence among Aboriginal British Columbians by sce-nario, 1980 to 2001Figure 1HIV prevalence among Aboriginal British Columbians by sce-nario, 1980 to 2001.0.00.51.01.52.01980 1985 1990 1995 2000YearHIVprevalenceHighLowPage 4 of 6(page number not for citation purposes)The high prevalence of HIV occurring among BritishColumbian Aboriginals was mainly due to increases inthe same pattern of condom usage as non-Aboriginal per-sons in this cohort.Harm Reduction Journal 2005, 2:26 http://www.harmreductionjournal.com/content/2/1/26Our results point to a number of important policy impli-cations and gaps in knowledge. If our estimates of injec-tion drug users are correct then a considerable number ofinjection drug users are living outside of Greater Vancou-ver and likely do not have the same access to harm reduc-tion services or have to travel further to get to them.Persons outside of Vancouver and Victoria are known tohave limited access to drug rehabilitation program or tomethadone. The effectiveness of needle exchanges inplaces like Campbell River, Chilliwack, Gibsons, Kam-loops, Kelowna, Nanaimo, Powell River, Prince George,Prince Rupert, Quesnel, Surrey, and Veron is also not wellcharacterized. Little is known about HIV prevalence ofinjection drug users at these sites, and whether reportedrates are higher as or much lower than those observed inVancouver and Victoria.Although the population of Aboriginal gay and bisexualmen is small it still accounts for a large proportion of HIVinfections. Little is known about how much of male tomale sexual activity is attributed to sex work. Future pre-vention work in this community needs to be targeted,even though these men are more likely to be more mar-ginalized and in the sex trade than their non-Aboriginalgay and bisexual counterparts[9].Finally, the spread of HIV to the general Aboriginal popu-lation is not well characterized. There is no conclusive evi-dence to suggestion that the increase in seroprevalenceamong pregnant women and low risk men is not directlyand to antenatal care. Currently, few Aboriginal womenwho have HIV-positive children are able to seek adequatecare for themselves or their children[20]. Access to antiret-roviral therapy among those infected needs to beimproved. Aboriginal British Columbians are also notaccessing treatment at the same rate as non-Aborigi-nals[29]. Differences in access are likely attributed to dif-ferences in living conditions, access to physicians, as wellas the remoteness of some communities.In conclusion, more than 1 in every 100 adults aged 15years and over was living with HIV in 2001. The rate ofinfection observed in this study was greatly affected by thesize of the injection drug user population and the spreadof HIV into the general population. Governments andnon-government organizations need to work together toensure the funding of culturally appropriate HIV preven-tion programs.AcknowledgementsThis work was supported by the Michael Smith Foundation for Health Research through a Senior Scholar Award to Dr. Hogg. Dr. Strathdee is supported through the foundation for the Harold Simon Chair, as well as grants from the National Institute on Drug Abuse (DA12568, DA14499 and DA09225).We thank Simon Bonner, Keith Chan, Kevin Craib, Bonnie Devlin, Nada Gataric, Kathy Li, Patti Spittal, Peter Vann, and Benita Yip for their research assistance. I would also like to acknowledge the assistance of Drs. Tim Brown, Wiwat Peerapatanapokin, and Tobi Saidel of the East West Centre.References1. Wright J: HIstory of the Native People of Canada.  In (10,000 to1,000 B.C.) Volume I. Ottawa: Archaeological Survey of Canada; 1995. 2. Fladmark K: Routes: alternate migration corridors for earlyman in north america.  American Antiquity 1979, 44(1):55-69.3. Bobrowsky PT, Rutter N: Geologic evidence for an Ice-Free-Corridor in northeastern British Columbia, Canada.  CurrentResearch in the Pleistocene, Paleoenvironments: Geosciences 1990,7:133-135.4. Duff W: The Impact of the White Man, The Indian History of BritishColumbia Volume 1. Victoria: Provincial Museum of Natural Historyand Anthropology; 1965. 5. Romaniuk A: Increase in natural fertility during the earlystages of modernization: Canadian Indians case study.Demography 1981, 18:157-172.6. Johansson SR: The demographic history of the native peoplesof North America: a selective bibliography.  Yearb PhysAnthropol 1982, 25:133-52.7. Wang L, Noertjojo K, Elwood RK, FitzGerald JM: Tuberculosisamong aboriginal and nonaboriginal persons in BritishColumbia.  Can Respir J 2000, 7(2):151-7.8. Craib KJ, Spittal PM, Wood E, Laliberte N, Hogg RS, Li K, et al.: Riskfactors for elevated HIV incidence among Aboriginal injec-tion drug users in Vancouver.  CMAJ Canadian Medical AssociationJournal 2003, 168(1):19-24.9. Heath KV, Cornelisse PG, Strathdee SA, Palepu A, Miller ML, Schech-ter MT, et al.: HIV-associated risk factors among young Cana-dian Aboriginal and non-Aboriginal men who have sex withmen.  Int J STD AIDS 1999, 10(9):582-7.10. Weber AE, Craib KJ, Chan K, Martindale S, Miller ML, Schechter MT,et al.: Sex trade involvement and rates of human immunode-ficiency virus positivity among young gay and bisexual men.Table 2: Estimated prevalence and number of Aboriginal British Columbians living with HIV in 2001*Monte Carlo SimulationVariable Estimate 2.5 and 97.5th percentilesPopulation aged 15 and above 117,800HIV prevalence 1.44% 1.26% – 1.66%HIV infectedMales 935 822 – 1,072Females 756 652 – 887Total 1,691 1,479 – 1,955HIV infected by groupGay and bisexual men 186 145 – 232Injection drug users 1,458 1,202 – 1,744Low-risk men 15–49 years 16 3 – 29Low risk women 15–49 years 23 6 – 41Low-risk population 50 years and over6 5 – 7* Derived from the results of 100,000 Monte Carlo simulation trials.Page 5 of 6(page number not for citation purposes)attributable to injection drug use. We need to ensure thatall Aboriginal pregnant women have access to HIV testingInt J Epidemiol 2001, 30(6):1449-54.11. O'Connell JM, Lampinen TM, Weber AE, Chan K, Miller ML, Schech-ter MT, et al.: Sexual risk profile of young men in Vancouver,Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Harm Reduction Journal 2005, 2:26 http://www.harmreductionjournal.com/content/2/1/26British Columbia, who have sex with men and inject drugs.AIDS Behav 2004, 8(1):17-23.12. Inventory of HIV incidence and prevalence studies in Canada Ottawa: Divi-sion of HIV/AIDS Epidemiology and Surveillance, Centre for Infec-tious Disease Prevention and Control, Population and Public HealthBranch, Health Canada; 2002. 13. Canada S: Aboriginal Peoples Survey 2001 – initial findings:Well-being of the non-reserve Aboriginal Population.Ottawa: Statistics Canada; 2003. 14. Fay RE, Turner CF, Klassen AD, Gagnon JH: Prevalence and pat-terns of same gender sexual contact among men.  Science1989, 243:338-43.15. Remis RS, Leclerc P, Routledge R, Taylor C, Bruneau J, Beauchemin J,Millson P, Palmer WH, Degani N, Strathdee S, Hogg R: Consortiumto characterize injection drug users in Canada (Montreal,Toronto, and Vancouver).  Ottawa: Division of HIV/AIDS Epide-miology Research, Bureau of HI/AIDS and STD, Laboratory Centrefor Disease Control, Health Canada; 1998. 16. Regional analysis of health statistics for status Indians in Brit-ish Columbia 1991–2001.  In Birth related and mortality summariesfor British Columbia and 16 health service delivery areas Victoria: BritishColumbia Vital Statistics Agency, Ministry of Health Planning, Provinceof British Columbia and First Nations and Inuit Health Branch, HealthCanada; 2002. 17. Trussler T, Marchand R, Barker A: Sex now by the numbers : astatistical guide to health planning for gay men.  Vancouver:Community-Based Research Centre; 2003. 18. Spittal PM, Craib KJ, Wood E, Laliberte N, Li K, Tyndall MW, et al.:Risk factors for elevated HIV incidence rates among femaleinjection drug users in Vancouver.  CMAJ Canadian Medical Asso-ciation Journal 2002, 166(7):894-9.19. Martin JD, Mathias RG, Sarin C, Byrne SE: HIV and hepatitis B sur-veillance in First Nations alcohol and drug treatment centresin British Columbia, Canada, 1992–2000.  Int J CircumpolarHealth 2002, 61(2):104-9.20. Ogilvie G, Money DM, Forbes JC, Remple VP, Alimenti A, Burdge DP:Perinatal HIV infection in Aboriginal maternal infant pairs(MIP) in British Columbia.  Can J Infect Dis 2002, 13(Supple-ment A):50A. {Abstract 321}.21. Stajduhar KI, Poffenroth L, Wong E: Missed opportunities:putting a face on injection drug use and HIV/AIDS in theCapital Health Region.  Vancouver: CHEOS; 2002. 22. UNAIDS: Estimating and projecting national HIV/AIDS epi-demics.  The models and methodology of the UNAIDS/WHO approachto estimating and projecting national HIV/AIDS epidemics 2003.23. Canada H: HIV/AIDS Among Aboriginal Persons in Canada: AContinuing Concern.  Ottawa: Centre for Infectious Disease Pre-vention and Control; 2002. 24. Miller CL, Wood E, Spittal PM, Li K, Frankish JC, Braitstein P, et al.:The Future Face of Coinfection: Prevalence and Incidence ofHIV and Hepatitis C Virus Coinfection Among Young Injec-tion Drug Users.  J Acquir Immune Defic Syndr 2004, 36(2):743-749.25. Fischer B, Rehm J, Blitz-Miller T: Injection drug use and preven-tive measures: a comparison of Canadian and Western Euro-pean jurisdictions over time.  CMAJ 2000, 162(12):1709-13.26. Miller CL, Tyndall M, Spittal P, Li K, Palepu A, Schechter MT: Risk-taking behaviors among injecting drug users who obtainsyringes from pharmacies, fixed sites, and mobile van needleexchanges.  J Urban Health 2002, 79(2):257-65.27. Wood E, Tyndall MW, Spittal PM, Li K, Hogg RS, Montaner JS, et al.:Factors associated with persistent high-risk syringe sharingin the presence of an established needle exchange pro-gramme.  Aids 2002, 16(6):941-3.28. Tyndall MW, Patrick D, Spittal P, Li K, O'Shaughnessy MV, SchechterMT: Risky sexual behaviours among injection drugs userswith high HIV prevalence: implications for STD control.  SexTransm Infect 2002, 78(Suppl I):i170-i175.29. Wood E, Montaner JSG, Tyndall MW, Schechter MT, O'ShaughnessyMV, Hogg RS: Prevalence and correlates of untreated HIV-1infection among persons who have died in the era of modernantiretroviral therapy.  Journal of Infectious Diseases 2003,188:1164-70.yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 6 of 6(page number not for citation purposes)

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