I-Track - Enhanced Surveillance of Risk Behaviours among Injecting Drug Users in Canada

Pilot Survey Report, February 2004

Table of Contents

• List of Tables
• Acknowledgements
• Executive summary

1.	Introduction
	1.1	The need for surveillance of risk behaviours among injecting drug users in Canada
	1.2	Background
	1.3	Development of system for surveillance of risk behaviours among injecting drug users in Canada
	1.4	Collaboration
	1.5	Participating Centres

2.	Objectives of surveillance of risk behaviours among IDU populations across Canada
	2.1	Objectives
	2.2	Pilot Survey Objectives
3.	Methods
	3.1	Survey Design
	3.2	Eligibility Criteria
	3.3	Sample Size
	3.4	Survey Staff and Training
	3.5	Sampling and recruitment
	3.6	Summary of Recruitment methods and sample size by center
	3.7	Data Collection
		3.7.1	Questionnaire
		3.7.2	Additional questions of local interest
	3.8	HIV and hepatitis C testing
		3.8.1	Dried Blood Spot Collection
		3.8.2	Interviewer assistance with DBS collection
		3.8.3	Laboratory Testing
4.	Data Analysis
5.	Results
	5.1	Socio-Demographic Characteristics of Participants
	5.2	Drug use
	5.3	Sexual relationships
	5.4	HIV and Hepatitis C Testing
	5.5	Representativeness of the study population
6.	Discussion
7.	Conclusions and Recommendations
8.	References
Appendix A: Core Questionnaire Pilot Phase PDF only 8 pages 232 KB
Appendix B: Evaluation of Study Methods

List of Tables

Table 1.	Mode of recruitment, survey timeframes and sample size conducted between October 2002 and February 2003 by centre
Table 2.	Number and gender distribution of participants
Table 3.	Age group distribution
Table 4.	Age distribution by gender
Table 5.	Highest education level completed
Table 6.	Current residence
Table 7.	Past residence within the past 6 months
Table 8.	Types of places where participants have lived in the past 6 months
Table 9.	Type of place where participants currently live
Table 10.	Ethnic background
Table 11.	Drugs injected, by site
Table 12.	Non-injected drugs, by site
Table 13.	Seven most common injected drugs, by site
Table 14.	Age of injection initiation
Table 15.	Frequency of injection in the preceding one month
Table 16.	Participant injecting behaviour, by site
Table 17.	Partner with whom participant injects most often during past past 6 months
Table 18.	Number of participants who injected with used needles/syringes during past 6 months
Table 19.	Number of participants who injected with used injection equipment during past 6 months
Table 20.	Partner from whom participant borrowed used needles/syringes during past 6 months
Table 21.	Partner from whom participant borrowed needles/syringes most often during past 6 months
Table 22.	Partner from whom participant borrowed used injection equipment during past 6 months
Table 23.	Partner from whom participant borrowed injection equipment most often during past 6 months
Table 24.	Participants who lent used needle/syringes to someone else during past 6 months
Table 25.	Participants who lent used injection equipment to someone else
Table 26.	Frequency of sharing used needles or syringes in preceding one month
Table 27.	Frequency of sharing other used injection equipment in preceding one month
Table 28.	Sexual activity during past 6 months
Table 29.	Females with reported male partners during past 6 months
Table 30.	Type of male sex partner(s) reported by female study population during past 6 months
Table 31.	Number of females who had penetrative or oral sex with their male sex partner(s) during past 6 months
Table 32.	Frequency of condom use by female participants who had penetrative or oral sex with male partners
Table 33.	Males with reported female sex partners
Table 34.	Type of female sex partner(s) reported by males during past 6 months
Table 35.	Number of males who reported having had penetrative or oral sex with female partners during past 6 months
Table 36.	Frequency of condom use by male participants who had penetrative or oral sex with female partner during past 6 months
Table 37.	Number of MSM participants
Table 38.	Type of MSM partner
Table 39.	Number of male participants who had penetrative or oral sex with their male partners
Table 40.	Frequency of condom use by male participants with male sex partners during past 6 months
Table 41.	Number of participants ever tested for HIV
Table 42.	Reported number of tests done and number of participants tested in the last two years
Table 43.	Number of times participants tested for HIV in the last two years
Table 44.	Number of participants reporting HIV testing and reported year of testing
Table 45.	Frequency of HIV testing
Table 46.	Number of HIV positive people under a doctor's care for HIV by site
Table 47.	Number of self-reported HIV positive participants taking drugs for their HIV
Table 48.	HIV Prevalence by site
Table 49.	Self-Reported HIV result, by site
Table 50.	Self-reported and actual HIV result at four sites combined
Table 51.	Self-reported and Actual HIV result by site
Table 52.	Number of people previously tested for HCV
Table 53.	Date of most recent HCV test
Table 54.	HCV Prevalence by site
Table 55.	Self-reported past HCV result where testing was done
Table 56.	Self-reported and actual HCV result for four sites combined
Table 57.	Self-reported and actual HCV result by site
Table 58.	Number of HCV positive people under the care of a doctor for HCV
Table 59.	Number of people taking drug for HCV
Table 60.	HIV and HCV Co-infection Rates by site
Table 61.	Characteristics of Study population compared to those of IDU attending the Victoria NEP
Table 62.	Use of NEP by study population by site
Table 63.	Comparison of characteristics of NEP-users vs. Non NEP-users

Acknowledgements

The I-Track Enhanced Surveillance of Injecting Drug Users Risk Behaviours Pilot Survey was a result of collaboration between Health Canada and researchers, provincial health authorities and community-based organizations from participating centres across Canada. The team associated with this pilot survey report include:

EXPERT ADVISORY GROUP
Dr. Michel Alary (SurvUDI Research Group, Quebec), Dr. Lawrence Elliot (University of Manitoba), Dr. Peggy Millson (University of Toronto), Dr. Mark Tyndall (University of British Columbia, and BC Centre for Excellence in HIV/AIDS), Dr. Chris Archibald (CIDPC, Health Canada), Jennifer Siushansian (formerly of CIDPC, Health Canada)

REGINA
Regina Qu'Appelle Health Region, Regina Needle Exchange Programs, Dr. Maurice Hennink, Charlotte Miller, Michelle Bilan, Carleen Rozon, Melina Tallentire

SUDBURY
Sudbury and District Health Unit, The Point Needle Exchange Program, Dr. Penny Sutcliffe, Dr. Peggy Millson, Doris Schwar, Kerry Elliot, Leonard Frappier, Kelly Ann Reilly

SurvUDI RESEARCH GROUP
Institut National de Santé Publique du Québec, SurvUDI Working Group, Dr. Michel Alary, Raymond Parent, Dr. Carole Morissette, Élise Roy, Dr. Catherine Hankins, Caty Blanchette, Jacque Boissinot, Andrée Côté, Jocelyne Daigneault, Marcel Gauthier, Lina Noël, Jacques Dumont, Serge Laforge, Lynne Leonard, Andrée Perrault, Christiane Claessens

TORONTO
Toronto Public Health, The Works Needle Exchange Program, Queen West Community Health Centre Needle Exchange Program and staff, Dr. Peggy Millson, Shaun Hopkins, Deborah Gardner, Kimberly Wolak, Leah Boelhouwer, Sandra Ludzig, Sharlene Cobain, Maria Catalli, Brenda Melo, Raffi Balian of the South Riverdale Community Health Centre, Youthlink Inner City

VICTORIA
Vancouver Island Health Authority South, AIDS Vancouver Island, Nurses of the Street Outreach Program of Vancouver Island, Dr. Richard Stanwick, Dr. Linda Poffenroth, Audrey Shaw, Dana Carr, John Urh, Charlene Heilman

CENTRE FOR INFECTIOUS DISEASE PREVENTION AND CONTROL, Public Health Agency of Canada, HEALTH CANADA

Surveillance and Risk Assessment Division
Dr. Chris Archibald, Dr. Yogesh Choudhri, Kathleen Lydon-Hassen, Tara Smith, Linh-An Tuong

National HIV and Retrovirology Laboratories
Dr. Paul Sandstrom, Dr. John Kim, Laurie Malloch

Community Acquired Infections Division
Dr. Tom Wong, Tracey Donaldson, Amrita Paul

HIV/AIDS Policy, Coordination and Programs Division
Jacqueline Arthur

SPECIAL THANKS TO:
The I-Track Study participants in all participating centres.

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Executive Summary

Introduction

The Injecting Drug Use Unit of the Surveillance and Risk Assessment Division, CIDPC, is establishing an enhanced surveillance system to track HIV- and hepatitis C (HCV) - associated risk behaviours in injecting drug users (IDU) populations (I-Track) in urban and semi-urban centres across Canada. It forms a part of the second-generation HIV surveillance as advocated by WHO and UNAIDS. Through this system, national, and to a certain extent provincial and local, trends in injecting and sexual risk behaviours among IDU can be assessed. Behavioural trend data obtained through the system will provide important information that can be triangulated with other data sources to assess the effects of prevention efforts and policies at the local, provincial, and national levels. The surveillance system is being established in collaboration with local and provincial health departments, community-based organizations and researchers. Within Health Canada, internal collaborations involve the Community Acquired Infections Division, the National HIV and Retrovirology Laboratory and the HIV/AIDS Policy, Coordination and Programs Division.

Objectives

The objectives of national surveillance of HIV/HCV-associated risk behaviours among IDU in Canada are to describe changing patterns in drug injecting practices, HIV-testing behaviours and sexual behaviours among IDU. Depending on the feasibility of collecting a biological sample (and the type of biological sample that is collected), additional objectives are:

• To describe changing patterns in the prevalence and incidence of HIV infections among IDU at the national and local level.
• To describe changing patterns in the prevalence and incidence of hepatitis C (HCV) infections among IDU at the national and local level.

Pilot Study

The pilot study was undertaken during 2002 and 2003 in Regina, Sudbury, Toronto, and Victoria to assess the feasibility of the proposed methods for conducting behavioural surveillance of IDU populations across Canada. In addition, the SurvUDI group, which has been conducting studies among IDU at selected centres in Quebec and Ottawa since 1995, piloted the questionnaire and studied the feasibility of collection of biological specimen.

The pilot study assessed the feasibility and mechanism of development of a national level surveillance system and its sustainability in the long run. A review of the pilot study was carried out in a meeting held on March 27th and 28th, 2003 wherein, feedback from each of the participating centres was discussed, and the pilot phase was evaluated with respect to the objectives. The meeting also laid the foundation for establishment of a national risk behaviour surveillance system among IDU in Canada.

Results of the pilot study

A total number of 794 participants were recruited from four cities viz. Toronto (221), Regina (254), Sudbury (169), and Victoria (150). In addition, the SurvUDI group has recently (August, 2003) finished recruitment of 257 IDU to conduct the pilot. The survey instrument consisted of 35 core questions and site-specific questions were added depending on site requirements. The biological surveillance was undertaken through collection of dried blood specimens (DBS) at four sites. The SurvUDI collected DBS for over 90 participants, venous and saliva sample for nearly 60 participants and only saliva sample for the remaining participants. This report contains results of the survey completed in four cities viz. Toronto, Regina, Sudbury, and Victoria and the report on the evaluation of the pilot at the participating centres including SurvUDI group. The results of the pilot study undertaken by SurvUDI will be presented separately.

Recruitment

Recruitment was mainly carried out at the needle exchange program (NEP) centres or their mobile and outreach services and through word-of-mouth. At some sites, promotion of the survey was done through flyers and posters that were displayed at prominent sites being frequented by the IDU.

Demographics of the study population

The study population comprised 514 (64.8%) males and 279 (35.2%) females (information on gender was missing for one participant). The mean age of the study population was 35 years (range 16 to 69), and was higher for males (36.4 years) as compared to females (32.2 years). Nearly 97% of the study population was living in the city of recruitment although 3% of the study participants came from adjoining cities to participate in the survey. In terms of level of education, 44.5% of participants had completed high school or above, and 55.5% of participants had some high school or less. Nearly 40% of the study participants identified themselves to be Aboriginal and of these nearly 60% were recruited in Regina, where nearly 90% of the study population identified themselves as Aboriginal. Just over half of the study population reported having stable housing (living in their own house or apartment or parent's/relative's house) and 8% were living with friends. Among the study participants 9% were living in shelters and 8% were living on the street at the time of recruitment.

Drug use

One-third of the study population reported injecting drugs every day and 19.6% injected drugs once in a while, not every week. The mean age of injecting drug use initiation was 21.4 years (range 7-53 years) and one third of the study population had started to inject by the age of 16 years. The commonly injected drugs included cocaine used by 81.9% of IDU, morphine 54.3%, dilaudid 50.2%, heroin 42.8%, crack 30.5%, ritalin alone 26.3%, and talwin and ritalin 22.6% of IDU. The drugs injected varied by city: for example in Regina, the majority of IDU reported ritalin alone (or in combination with talwin) as the most commonly injected drug, while in Victoria it was cocaine. In Toronto, a large proportion of IDU reported injecting crack most often, but its use was limited in other cities.

Seroprevalence of HIV and Hepatitis C

The seroprevalence of HIV (average of four sites) was 8.1% among the study participants and varied by city [Regina 1.2%, Toronto 5.1%, Sudbury 10.1%, and Victoria 16.0%]. The seroprevalence of Hepatitis C was 63.8% (average of four sites) and varied by city [Toronto 54.3%, Regina 60.2%, Sudbury 61.5%, and Victoria 79.3%]. The HIV/HCV co-infection rate was found to be 7.8% (average of four sites).

Sharing of needles and injecting equipment

When asked about sharing needles and other injecting equipment such as cookers, water, cotton, filter etc. within six months prior to participating in the study, almost a quarter of the study population reported borrowing needles for injection. Needles were mostly borrowed from close friend/family or sex partners. In terms of other injection equipment, 43.2% of the study population had borrowed cookers, water, cotton, filter etc. mostly from close friend/family or regular sex partners. Almost a third of the study participants reported passing on injecting equipment they had used to others. Nearly 20% and 40% of the study population reported borrowing needle and other injecting equipment respectively for injections within one month prior to participating in the study.

Sexual behaviours

A significant proportion (84.7%) of the study population (including 80.4% of males and 94.9% females) across the four sites reported engaging in some kind of sexual activity during the preceding 6 months. Nearly 40% of females IDU reported having client male sex partners, 7.1% of the males had female client sex partners and 4.3% of the males reported having a male sexual partner within six months prior to study. Condom use during penetrative sex was higher compared with condom use during oral sex. Condom use during penetrative and oral sex became more infrequent as the IDU developed more stable relationships with their sexual partners. Condom use during penetrative sex was higher in the group of IDU who were aware of their HIV positivity as compared to those who knew that they were HIV negative.

Testing behaviours

In terms of HIV/ HCV testing, 89.7% and 85.3% of the study population, who responded to this question, reported that they had ever been tested for HIV and HCV, respectively. The proportions varied by site with nearly 96% of the study population in Victoria and 83.4% in Regina reported having been tested for HIV. In Regina, 83.8% of the study population was ever tested for HCV as compared to Victoria, where 94.0% of the participants were tested for HCV. When asked about testing for HIV in the one-year period preceding the study, 72.7% in Victoria, 52.0% in Regina, 58.0% in Sudbury, and 64.7% in Toronto reported being tested.

Conclusions

The results of the pilot study indicated that the prevalence of HIV and HCV remains unacceptably high in IDU populations in Canada. There is a high level of needle sharing and multi-person use of other drug injecting paraphernalia, and high rates of sexual activity, highlighting that the conditions exist for the spread of blood-borne viruses and sexually transmitted infections among networks of IDU. Ongoing monitoring of risk behaviours in IDU populations in urban and semi-urban locales is essential for program planning and evaluation and I-Track is able to provide such information at the national and local levels. The success of the pilot study indicates that a national surveillance system for monitoring of risk behaviours in IDU populations can be established in Canada with the collaboration of local and provincial health authorities, community-based organizations and researchers.

Phase I of the study is proposed to be undertaken in fall of 2003 in Victoria, and in the spring of 2004 in Regina, and Winnipeg, Toronto and Sudbury. The SurvUDI research group will continue to collaborate by ongoing recruitment at eight sites in Quebec and in Ottawa. Efforts are being made to recruit additional sites in the surveillance system in the future.

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I-Track - Enhanced Surveillance of Risk Behaviours among Injecting Drug Users in Canada: Pilot Survey Report, February 2004
Complete Report - PDF Version (73 pages, 669 KB)