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Willingness to Engage in Peer-Delivered HIV Voluntary Counselling and Testing Among People Who Inject… Markwick, Nicole; Ti, Lianping; Callon, Cody; Feng, Cindy X.; Wood, Evan; Kerr, Thomas Apr 3, 2014

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WILLINGNESS TO ENGAGE IN PEER-DELIVERED HIV VOLUNTARY COUNSELLING AND TESTING AMONG PEOPLE WHO INJECT DRUGS IN A CANADIAN SETTINGNicole Markwick1,2, Lianping Ti1,2, Cody Callon1, Cindy Feng3, Evan Wood1,4, and Thomas Kerr1,41 British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y62 School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, CANADA, V6T 1Z93 School of Public Health, University of Saskatchewan, 107 Wiggins Road, Saskatoon, SK, CANADA, S7N 5E54 Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, CANADA, V6T 1Z4AbstractBackground—People who inject drugs (IDU) face unique systemic, social and individual barriers to conventional HIV voluntary counselling and testing (VCT) programs. Peer-delivered approaches represent a possible alternative to improve rates of testing among this population.Methods—Cross-sectional data from a prospective cohort of IDU in Vancouver, Canada were collected between December 2011 and May 2012. Bivariate statistics and multivariate logistic regression were used to identify the prevalence of and factors associated with willingness to receive peer-delivered VCT.Results—Of 600 individuals, 51.5% indicated willingness to receive peer-delivered pretest counselling, 40.7% to receive peer-delivered rapid HIV testing, and 42.8% to receive peer-delivered post-test counselling. Multivariate analyses found significant positive associations between willingness for pre-test counselling and having used Vancouver’s supervised injection facility, Insite, or being a member of VANDU (a local drug user organization) (all p < 0.05). Daily crack smoking and having used Insite were positively associated with willingness to receive peer-delivered HIV testing (p < 0.05). Willingness to receive peer-delivered post-test counselling was positively associated with male gender, daily crack smoking, having used Insite, and being a member of VANDU (p<0.05).Conclusion—While not universally acceptable, peer-delivered VCT approaches may improve access to HIV testing among IDU.Send correspondence to: Thomas Kerr, PhD, Director, Urban Health Research Initiative, B.C. Centre for Excellence in HIV/AIDS, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada, Tel: (604) 806-9116, Fax: (604) 806-9044, uhri-tk@cfenet.ubc.ca. HHS Public AccessAuthor manuscriptJ Epidemiol Community Health. Author manuscript; available in PMC 2015 November 20.Published in final edited form as:J Epidemiol Community Health. 2014 July ; 68(7): 675–678. doi:10.1136/jech-2013-203707.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptKeywordsPeer-delivered; Voluntary HIV counselling and testing; People who inject drugs; VancouverINTRODUCTIONGlobally, people who inject drugs (IDU) constitute 5-10% of individuals living with HIV.[1] IDU face an heightened risk of HIV infection, largely due to shared drug paraphernalia including syringes and crack pipes.[2, 3] In Canada, an estimated 13.4% of those living with HIV are IDU.[2] Although earlier diagnosis of HIV through testing has been shown to improve health outcomes and survival of patients,[4] IDU often present to healthcare only after AIDS-related opportunistic infections have developed.[3] Further benefits of routine HIV voluntary counselling and testing (VCT) include reduced risk behaviours conducive to HIV transmission and increased uptake of antiretroviral therapy following diagnosis.[5, 6]Many barriers to VCT among IDU have been identified; distrust of the healthcare system and primary care providers are leading concerns.[7, 8] Peer-delivered VCT represents a unique opportunity to circumvent these barriers. In various studies, health services delivered by non-medical providers were shown to lower financial costs and result in equal or improved quality of care and service uptake, particularly among hard-to-reach populations.[8-13]Certain organizations in Vancouver’s Downtown Eastside neighbourhood, such as the supervised injection facility Insite (at which IDU can inject pre-obtained illicit drugs under nurse supervision), and the community organization Vancouver Area Network of Drug Users (VANDU), incorporate peer-delivery into their programming.[14] However, little is known about the acceptability of peer-delivered VCT among the IDU population, as no such programs currently exist. Therefore, this research sought to characterize IDU’s willingness to receive peer-delivered VCT in Vancouver, Canada.METHODSData for this research were drawn from the Vancouver Injection Drug Users Study (VIDUS), a prospective cohort of HIV-negative IDU recruited through street outreach and self-referral since 1996. The study has been described in detail previously.[15] Participants complete baseline and semi-annual follow-up questionnaires that elicit a range of information, including demographic data, information on drug use and HIV risk behaviours, and experiences with healthcare. Blood samples are also collected for serologic testing. The VIDUS study has been approved by the University of British Columbia/Providence Healthcare Research Ethics Board.This study employs cross-sectional data from participants who completed a survey between December 2011 and May 2012 (n=600). Seven (1.2%) observations with missing data were excluded from analysis. During this follow-up period only, new survey questions asked respondents who they would want to administer HIV pre-test counselling, rapid HIV test, and HIV post-test results and counselling. For each question, possible responses included: Markwick et al. Page 2J Epidemiol Community Health. Author manuscript; available in PMC 2015 November 20.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscriptdoctor, nurse, outreach/community worker, peer from Insite, someone from VANDU, close friend, acquaintance, someone with street experience, social worker, HIV support worker, HIV specialist (doctor), anyone (it doesn’t matter who), or other. Participants selected all that applied, thus categories were not mutually exclusive. Participants were considered willing to receive peer-delivered services if they selected at least one of: an Insite or VANDU peer, a close friend, acquaintance, someone with street experience, or anyone, as these categories are generally comprised of current or former members of the IDU community. The three distinct outcomes explored by this study are willingness to receive peer-delivered pretest counselling, peer-delivered rapid HIV testing and peer-delivered post-test counselling.Pearson’s Chi-squared tests were conducted for bivariate analysis, except where 5 or fewer individuals existed in one or more cells. In this instance, Fischer’s exact test was used. Odds ratios were calculated using simple logistic regression analyses. Three multivariate regression models were then constructed using the Akaike information criterion (AIC) and p-values. Each of the three models were initially constructed to include all variables where p<0.05 in bivariate analyses, then reduced by progressively removing the variable with the greatest p-value until no variables remained for inclusion. The model with the lowest AIC score was selected for reporting. All p-values were two-sided.RESULTSIn total, 600 participants were included in this study. Seven (1.2%) observations were excluded from analysis due to missing data. 195 respondents (32.5%) were female, 301 (50.2%) were aged ≥48 years, 375 (62.5%) self-identified as Caucasian, and 153 (25.5%) self-identified as Aboriginal. 143 (23.8%) respondents were current members of VANDU, 450 (75.0%) had used Insite in the past, and 136 (22.7%) reported smoking crack cocaine daily. Overall, 309 individuals (51.5%) indicated willingness to receive peer-delivered pre-test counselling, 244 (40.7%) to receive peer-delivered rapid HIV testing, and 257 (42.8%) indicated willingness to receive peer-delivered post-test counselling.In bivariate analyses, reported in Table 1, the following characteristics were significantly associated with willingness to receive peer-delivered pre-test counselling: drug dealing (Odds Ratio (OR) = 1.71, 95% confidence interval (CI): 1.10-2.65), daily crack smoking (OR = 1.59, 95%CI: 1.08-2.34), daily heroin injection (OR = 1.65, 95%CI: 1.05-2.61), injecting with others always or usually (OR = 1.66, 95%CI: 1.07-2.56), having used Insite (OR = 2.08, 95%CI: 1.42-3.03), and being a current member of VANDU (OR = 1.78, 95%CI: 0.54-2.07). Factors significantly associated with willingness to receive peer-delivered rapid HIV testing included drug dealing (OR = 1.70, 95%CI: 1.10-2.61), daily crack smoking (OR = 1.77, 95%CI: 1.20-2.60), daily heroin injection (OR = 1.65, 95%CI: 1.06-2.58), having used Insite (OR = 1.93, 95%CI: 1.30-2.87), and being a current member of VANDU (OR = 1.68, 95%CI: 1.15-2.45). Factors significantly associated with willingness to receive peer-delivered HIV test results and post-test counselling were daily crack smoking (OR = 1.63, 95%CI: 1.11-2.40), daily heroin injection (OR = 1.64, 95%CI: 1.05-2.57), injecting with others always or usually (OR = 1.64, 95%CI: 1.07-2.51), having Markwick et al. Page 3J Epidemiol Community Health. Author manuscript; available in PMC 2015 November 20.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscriptused Insite (OR = 2.00, 95%CI: 1.35-2.96), and being a current member of VANDU (OR = 1.67, 95%CI: 1.14-2.43).As shown in Table 2, multivariate analyses identified the following factors to be significantly associated with willingness to receive peer-based pre-test counselling: having used Insite (Adjusted odds ratio (AOR) = 1.85, 95%CI: 1.25-2.72), and being a current member of VANDU (AOR = 1.55, 95%CI: 1.04-2.30). Daily crack smoking (AOR = 1.70, 95%CI: 1.15-2.51) and having used Insite (AOR = 1.73, 95%CI: 1.15-2.59) were significantly associated with willingness to receive peer-delivered rapid HIV testing. Willingness to receive peer-delivered post-test counselling was significantly associated with male gender (AOR = 1.46, 95%CI: 1.02-2.10), frequent crack smoking (AOR = 1.55, 95%CI: 1.04-2.31), having used Insite (AOR = 1.73, 95%CI: 1.15-2.60), and being a current member of VANDU (AOR = 1.47, 95%CI: 1.00-2.18).DISCUSSIONOur study found moderately high levels of willingness to receive peer-delivered HIV VCT among IDU in Vancouver, Canada. Willingness was predicted by previous exposure to peer-delivered programming and markers of higher intensity drug use, specifically frequent crack smoking. These findings may reflect the potential for peer-based services to overcome various barriers to VCT associated with traditional VCT delivery. Specifically, peer-delivered VCT may help address issues such as lack of trust in the healthcare system, physicians’ unfamiliarity with the social conditions surrounding IDU, and discomfort awaiting test results.[7, 8] We found that more IDU were willing to receive peer-delivered pre-test counselling than testing and post-test counselling. A previous study from Thailand found similar results, which were later explained by concerns about confidentiality and peers’ ability to correctly administer tests.[16]IDU in our sample who had used Insite, Vancouver’s supervised injection facility which involves peer workers, or were members of the peer-run organization VANDU were more willing to engage in peer-delivered VCT. These results complement findings from a study in Thailand, which found that IDU who had engaged with a peer-run drop-in centre also expressed high willingness to receive peer-delivered VCT.[17] Given the potential importance of peer-delivery in the provision of HIV-related services, there may be value in implementing peer-delivered VCT within already established peer-run organizations to increase access to VCT within the community.High willingness for peer-delivered VCT among frequent crack cocaine users may be explained by previous research, which found that perceived risk exposure constituted a main reason to seek HIV testing.[7] Due to ongoing educational efforts in Vancouver’s Downtown Eastside, it is likely that IDU acknowledge crack cocaine use as a risk factor for HIV infection. Vancouver Coastal Health Authority’s crack pipe distribution program, which occurred between 2011 and 2012, represents one example of such efforts.[18]In Vancouver in 2011, a VCT pilot project delivered HIV counselling and testing to IDU through peers, in conjunction with nurses. An evaluation of the program found positive Markwick et al. Page 4J Epidemiol Community Health. Author manuscript; available in PMC 2015 November 20.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscriptresults, but no large-scale peer-delivered VCT was implemented.[19] Research in Melbourne, Australia, also investigated a program of peer-delivered hepatitis C counselling and testing among IDU and found improvement in risk behaviours and knowledge of hepatitis C.[20] The findings from the present study are consistent with these studies and provide evidence that IDU are willing to engage in peer-delivered VCT; these types of programs and services should therefore be brought to scale.Our study has limitations. First, our sample was built using snowball sampling methods and was not randomly selected; therefore, residual confounding may exist and results may not be generalizable. Second, we relied on self-reporting, which may subject our results to response bias. Lastly, our analysis is cross-sectional in nature and could be extended by future longitudinal and intervention research assessing how reported willingness compares to actual willingness to receive peer-delivered VCT.Overall, this study highlights the potential of supplementing traditional VCT strategies with peer-delivered approaches tailored to IDU.AcknowledgmentsThe authors thank the study participants for their contribution to the research, as well as current and past researchers and staff, with special thanks to Tricia Collingham. The study was supported by the US National Institutes of Health (R01DA011591). This research was undertaken, in part, thanks to funding from the Canada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine which supports EW.REFERENCES1. UNAIDS. UNAIDS report on the global AIDS epidemic 2013. Introduction, 2. Halve the transmission of HIV among people who inject drugs by 2015. 2013: http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf2. Mathers BM, Degenhardt L, Phillips B, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet. 2008; 372:1733–45. [PubMed: 18817968] 3. Vlahov D, Celentano DD. Access to highly active antiretroviral therapy for injection drug users: adherence, resistance, and death. Cad Saúde Pública. 2006; 22:705–18. [PubMed: 16612417] 4. Girardi E, Sabin CA, Monforte AD. Late diagnosis of HIV infection: epidemiological features, consequences and strategies to encourage earlier testing. J Acquir Immune Defic Syndr. 2007; 46(Suppl 1):S3–S8. [PubMed: 17713423] 5. Fonner V, Denison J, Kennedy C, et al. Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries. Cochrane Database of Syst Rev. 2012; 9 p.CD001224. 6. Wood E, Kerr T, Hogg RS, et al. Impact of HIV testing on uptake of HIV therapy among antiretroviral naive HIV-infected injection drug users. Drug Alcohol Rev. 2006; 25:451–4. [PubMed: 16939941] 7. Kellerman S, Lehman JS, Lansky A, et al. HIV testing within at-risk populations in the United States and the reasons for seeking or avoiding HIV testing. J Acquir Immune Defic Syndr. 2002; 31:202–10. [PubMed: 12394799] 8. Wood E, Kerr T, Tyndall MW, et al. A review of barriers and facilitators of HIV treatment among injection drug users. AIDS. 2008; 22:1247–56. [PubMed: 18580603] 9. Callaghan M, Ford N, Schneider H. A systematic review of task-shifting for HIV treatment and care in Africa. Hum Resour Health. 2010; 810. Morris MB, Chapula B, Chi BH, et al. Use of task-shifting to rapidly scale-up HIV treatment services: experiences from Lusaka, Zambia. BMC Health Serv Res. 2009; 9Markwick et al. Page 5J Epidemiol Community Health. Author manuscript; available in PMC 2015 November 20.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscript11. Broadhead RS, Heckathorn DD, Weakliem DL, et al. Harnessing peer networks as an instrument for AIDS prevention: results from a peer-driven intervention. Public Health Rep. 1998; 113:42. [PubMed: 9722809] 12. Hayashi K, Wood E, Wiebe L, et al. An external evaluation of a peer-run outreach-based syringe exchange in Vancouver, Canada. Int J Drug Policy. 2010; 21:418–21. [PubMed: 20359877] 13. van, Empelen P.; Kok, G.; van Kesteren, NM., et al. Effective methods to change sex-risk among drug users: a review of psychosocial interventions. Soc Sci Med. 2003; 57:1593–608. [PubMed: 12948569] 14. Kerr T, Small W, Peeace W, et al. Harm reduction by a “user-run” organization: a case study of the Vancouver Area Network of Drug Users (VANDU). Int J Drug Policy. 2006; 17:61–9.15. DeBeck K, Buxton J, Kerr T, et al. Public crack cocaine smoking and willingness to use a supervised inhalation facility: implications for street disorder. Subs Abuse Treat Prev Policy. 2011; 6:4.16. Ti, L.; Hayashi, K.; Hattirat, S., et al. ”Drug users stick together”: HIV testing in peer-based drop-in centres among people who inject drugs in Thailand. 11th International Congress on AIDS in Asia and the Pacific; Bangkok, Thailand: Nov. 2013 17. Ti L, Hayashi K, Kaplan K, et al. Willingness to access peer-delivered HIV testing and counseling among people who inject drugs in Bangkok, Thailand. J Community Health. 2013; 38:427–33. [PubMed: 23149569] 18. Olivier, C. Vancouver health body begins free crack pipe program for addicts. http://news.nationalpost.com/2011/12/30/vancouver-health-body-begins-free-crack-pipe-program-for-addicts/http://news.nationalpost.com/2011/12/30/vancouver-health-body-begins-free-crack-pipe-program-for-addicts/National Post 201119. Canadian AIDS Treatment Information Exchange. Peer HIV testing : programming connection case study. 2013. http://www.catie.ca/en/printpdf/pc/program/peer-testing-projecthttp://www.catie.ca/en/printpdf/pc/program/peer-testing-project20. Aitkin CK, Kerger M, Crofts N. Peer-delivered hepatitis C testing and couselling : a means of improving the health of injecting drug users. Drug Alcohol Rev. 2002; 21:33–37. [PubMed: 12189002] Markwick et al. Page 6J Epidemiol Community Health. Author manuscript; available in PMC 2015 November 20.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptWhat is already known on this subjectPeer-based approaches have been successful in delivering HIV-related interventions. This type of task-shifting from primary healthcare providers has been shown to increase quality of care and reduce costs of service delivery.Markwick et al. Page 7J Epidemiol Community Health. Author manuscript; available in PMC 2015 November 20.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptWhat this study addsThis study provides evidence that people who inject drugs (IDU) support the use of peer-delivered HIV voluntary counselling and testing (VCT). Associations between involvement with community services or peer-based networks indicate that these organizations may be key roll-out points for peer-based VCT services. Results also suggest that IDU who know they are participating in high-risk activities may be more likely to take advantage of low-barrier VCT opportunities.Markwick et al. Page 8J Epidemiol Community Health. Author manuscript; available in PMC 2015 November 20.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptMarkwick et al. Page 9Table 1Bivariate analyses of factors associated with willingness to receive peer-delivered pre-test counselling, rapid HIV testing, and post-test counselling among IDU in Vancouver, Canada (n=600)Willingness to receive peer-delivered pre-test counsellingWillingness to receive peer-delivered rapid HIV-testingWillingness to receive peer-delivered post-test counsellingCharacteristic Odds Ratio(95% CI)Odds Ratio(95% CI)Odds Ratio(95% CI)Age (≥ 48 years vs. < 48 years) 0.79 (0.57 - 1.08) 0.84 (0.61 – 1.16) 0.95 (0.69 – 1.31)Gender (male vs. female) 1.22 (0.86 – 1.71) 1.22 (0.86 – 1.73) 1.35 (0.95 – 1.91)Ethnicity (Asian vs. Caucasian) 0.39 (0.10 – 1.52) 0.16 (0.02 – 1.29) 0.32 (0.07 – 1.54) (Aboriginal vs. Caucasian) 1.13 (0.77 – 1.65) 1.19 (0.82 – 1.74) 1.06 (0.72 – 1.54) (Latin vs. Caucasian) 0.60 (0.17 – 2.17) 0.97 (0.27 – 3.49) 0.86 (0.24 – 3.10) (other vs. Caucasian) 0.57 (0.31 – 1.02) 0.71 (0.38 – 1.30) 0.68 (0.37 – 1.25)Drug dealing * (yes vs. no) 1.71 (1.10 – 2.65) 1.70 (1.10 – 2.61) 1.45 (0.95 – 2.23)Sex work * (yes vs. no) 1.91 (1.00 – 3.63) 1.66 (0.90 – 3.07) 1.66 (0.90 – 3.08)Crack smoking * (≥ daily vs. < daily) 1.59 (1.08 – 2.34) 1.77 (1.20 – 2.60) 1.63 (1.11 – 2.40)Heroin injection * (≥ daily vs. < daily) 1.65 (1.05 – 2.61) 1.65 (1.06 – 2.58) 1.64 (1.05 – 2.57)Cocaine injection * (≥ daily vs. < daily) 1.71 (0.74 – 3.94) 1.61 (0.72 – 3.60) 1.74 (0.78 – 3.90)Crystal methamphetamine injection * (≥ daily vs. < daily) 2.42 (0.93 – 6.33) 1.99 (0.83 – 4.81) 1.49 (0.62 – 3.56)Assisted injection * (yes vs. no) 1.48 (0.76 – 2.90) 1.68 (0.87 – 3.24) 1.52 (0.79 – 2.94)Inject with others * (always, usually vs. sometimes, occasionally, never) 1.66 (1.07 – 2.56) 1.51 (0.98 – 2.31) 1.64 (1.07 – 2.51)Having used Insite ** (yes vs. no) 2.08 (1.42 – 3.03) 1.93 (1.30 – 2.87) 2.00 (1.35 – 2.96)Incarceration * (yes vs. no) 1.22 (0.64 – 2.31) 1.15 (0.61 – 2.19) 1.29 (0.69 – 2.44)Current member of VANDU (yes vs. no) 1.78 (1.21 – 2.61) 1.68 (1.15 – 2.45) 1.67 (1.14 – 2.43)Barriers to accessing healthcare services (yes vs. no) 1.06 (0.54 – 2.07) 1.90 (0.96 – 3.74) 1.53 (0.78 – 3.01)J Epidemiol Community Health. Author manuscript; available in PMC 2015 November 20.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptMarkwick et al. Page 10IDU: people who inject drugs, CI: confidence interval, VANDU: Vancouver Area Network of Drug Users*Refers to behaviour/activities in the previous six months**Indicates that the participant has accessed services provided by Vancouver’s supervised injection facility, Insite, at least once in the pastJ Epidemiol Community Health. Author manuscript; available in PMC 2015 November 20.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptMarkwick et al. Page 11Table 2Multivariate logistic regression analyses of factors associated with willingness to receive peer-delivered pre-test counselling, rapid HIV testing, and post-test counselling among IDU in Vancouver, Canada (n=600)Willingness to receive peer-delivered pre-test counsellingWillingness to receive peer-delivered rapid HIV-testingWillingness to receive peer-delivered post-test counsellingCharacteristic AOR(95% CI)AOR(95% CI)AOR(95% CI)Gender(male vs. female) - - 1.46 (1.02 – 2.10)Sex work *(yes vs. no) 1.61 (0.83 – 3.15) - -Crack smoking *(≥ daily vs. < daily) 1.41 (0.94 – 2.11) 1.70 (1.15 – 2.51) 1.55 (1.04 – 2.31)Crystal methamphetamine injection *(≥ daily vs. < daily) 2.43 (0.92 – 6.44) - -Inject with others *(always, usually vs. sometimes, occasionally,never)- - 1.45 (0.93 – 2.26)Having used Insite **(yes vs. no) 1.85 (1.25 – 2.72) 1.73 (1.15 – 2.59) 1.73 (1.15 – 2.60)Current member of VANDU(yes vs. no) 1.55 (1.04 – 2.30) 1.44 (0.98 – 2.13) 1.47 (1.00 – 2.18)Barriers to accessing healthcare services(yes vs. no) - 1.80 (0.90 – 3.60) -IDU: people who inject drugs, CI: confidence interval, AOR: adjusted odds ratio, VANDU: Vancouver Area Network of Drug Users*Refers to behaviour/activities in the previous six months**Indicates that the participant has accessed services provided by Vancouver’s supervised injection facility, Insite, at least once in the pastJ Epidemiol Community Health. Author manuscript; available in PMC 2015 November 20.

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