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      Uptake of Community-Based Peer Administered HIV Point-of-Care Testing: Findings from the PROUD Study

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          Abstract

          Objectives

          HIV prevalence among people who inject drugs (PWID) in Ottawa is estimated at about 10%. The successful integration of peers into outreach efforts and wider access to HIV point-of-care testing (POCT) create opportunities to explore the role of peers in providing HIV testing. The PROUD study, in partnership with Ottawa Public Health (OPH), sought to develop a model for community-based peer-administered HIV POCT.

          Methods

          PROUD draws on community-based participatory research methods to better understand the HIV risk environment of people who use drugs in Ottawa. From March-October 2013, 593 people who reported injecting drugs or smoking crack cocaine were enrolled through street-based recruitment. Trained peer or medical student researchers administered a quantitative survey and offered an HIV POCT (bioLytical INSTI test) to participants who did not self-report as HIV positive.

          Results

          550 (92.7%) of the 593 participants were offered a POCT, of which 458 (83.3%) consented to testing. Of those participants, 74 (16.2%) had never been tested for HIV. There was no difference in uptake between testing offered by a peer versus a non-peer interviewer (OR = 1.05; 95% CI = 0.67–1.66). Despite testing those at high risk for HIV, only one new reactive test was identified.

          Conclusion

          The findings from PROUD demonstrate high uptake of community-based HIV POCT. Peers were able to successfully provide HIV POCT and reach participants who had not previously been tested for HIV. Community-based and peer testing models provide important insights on ways to scale-up HIV prevention and testing among people who use drugs.

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          Most cited references18

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          Late diagnosis of HIV infection: epidemiological features, consequences and strategies to encourage earlier testing.

          A substantial proportion of HIV-infected individuals do not present for HIV testing until late in infection; these individuals are often ill, have a high mortality risk, and are less likely to respond to treatment when initiated. Furthermore, late presentation means that opportunities to reduce onward transmission, either by reducing high-risk behaviours or by reducing an individual's infectivity, are missed. The proportion of HIV-infected individuals who present late has remained relatively stable over the past decade, despite several attempts to encourage earlier diagnosis. Late presenters tend to be those at lower perceived risk of infection, those who are not routinely offered HIV testing, and are often from marginalized groups. Strategies that encourage earlier testing, including routine HIV testing in healthcare settings where high-risk individuals attend frequently, the availability of HIV testing services in non-medical settings, and partner notification schemes or peer-led projects to encourage high-risk individuals to attend for testing, may all increase the proportion of HIV-infected individuals who are aware of their HIV status, thus helping to control the spread of the epidemic. This review summarizes recent evidence on the epidemiology of late presentation and its impact on clinical progression, and describes several key strategies that may encourage earlier diagnosis.
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            Choice of effect measure for epidemiological data.

            The debate concerning the choice of effect measure for epidemiologic data has been renewed in the literature, and it suggests some continuing disagreement between the pertinent clinical and statistical criteria. In this article, some defining characteristics of the main choices of effect measure [risk difference (RD), relative risk (RR), and odds ratio (OR)] for binary data are presented and compared, with consideration of both the clinical and statistical perspectives. Relationships of these measures to the relative risk reduction (RRR) and number needed to treat (NNT) are also discussed. A numerical comparison of models of constant RD, RR, and OR is made to assess when and by how much they might differ in practice. Typically the models show only small numerical differences, unless extreme extrapolation is involved. The RD and RR models can predict impossible event rates, either less than zero or greater than 100%. Each measure has potential theoretical justification. RD and RR may enjoy some advantages for communication of risk, but OR may be preferred for data analysis. A clear distinction should be maintained between the objectives of data analysis and subsequent risk communication, and different effect measures may be needed for each.
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              A review of barriers and facilitators of HIV treatment among injection drug users.

              Globally, injection drug use continues to account for a substantial proportion of HIV infections. There have not, however, been any evidence-based reviews of the barriers and facilitators of HIV treatment among injection drug users. For this review, published studies were extracted from nine academic databases, with no language or date specified in the search criteria. Existing evidence demonstrates that, although injection drug users often have worse outcomes from HIV treatment than non-injection drug users, major antiretroviral-associated survival gains still have been observed among this population. Inferior outcomes are explained by a range of barriers to antiretroviral access and adherence, which often stem from the negative influences of illicit drug policies, as well as issues within medical systems, including lack of physician education about substance abuse. Evidence demonstrates that several under-utilized interventions and novel antiretroviral delivery modalities have helped to greatly address these barriers in several settings, and there is sufficient evidence to support immediate scale-up of these programmes. These interventions include coupling antiretroviral therapy with opioid substitution therapies as well as directly administered antiretroviral therapy programmes. Of particular interest for future evaluation is the coupling of HIV treatment programmes within comprehensive services, which also provide low-threshold (harm reduction) HIV prevention programmes. Scale-up of evidence-based HIV treatment and prevention to injection drug users, however, will require increasing political will among both national policy-makers and international public health agencies.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                2 December 2016
                2016
                : 11
                : 12
                : e0166942
                Affiliations
                [1 ]Ottawa Hospital Research Institute, Ottawa, Canada
                [2 ]PROUD Community Advisory Committee, Ottawa, Canada
                [3 ]Drug Users Advocacy League, Ottawa, Canada
                [4 ]Department of Medicine, University of Ottawa, Ottawa, Canada
                [5 ]Ottawa Public Health, Ottawa, Canada
                [6 ]CT Lamont Primary Health Care Research Centre, Bruyere Research Institute, Department of Family Medicine, University of Ottawa, Ottawa, Canada
                [7 ]University of Ottawa at the Ottawa Hospital, Division of Infectious Diseases, Ottawa, Canada
                University of New South Wales, AUSTRALIA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: LL AS SL KM CH CK MWT.

                • Formal analysis: LL SP AS WP MWT.

                • Funding acquisition: MWT.

                • Methodology: LL SP AS SL KM CH CK MWT.

                • Software: SP WP.

                • Writing – original draft: LL.

                • Writing – review & editing: LL SP AS SL CL MH KM CH WP CK MWT.

                ¶ PROUD Community Advisory Committee members are thanked in the Acknowledgments

                Article
                PONE-D-16-24539
                10.1371/journal.pone.0166942
                5135055
                27911908
                505a04f5-57a3-4a81-9387-faff3e318801
                © 2016 Lazarus et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 18 June 2016
                : 6 November 2016
                Page count
                Figures: 0, Tables: 3, Pages: 11
                Funding
                Funding has been received for this work from the Canadian Institutes of Health Research (FRN 134048; http://www.cihr-irsc.gc.ca/e/193.html), the Ontario HIV Treatment Network ( http://www.ohtn.on.ca), and The Ottawa Hospital, Department of Medicine and Division of Infectious Diseases ( https://www.ottawahospital.on.ca). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
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                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Immunodeficiency Viruses
                HIV
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
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                Custom metadata
                Data pertaining to people who use drugs are highly sensitive in nature given the criminalization of drug use in the Canadian context. We are therefore not able to make the database publicly available in order to fully protect participants’ confidentiality. To achieve access to the data used in this paper, interested researchers should contact Dr. Claire Kendall at ckendall@ 123456uottawa.ca . Data are from the PROUD study whose authors may be contacted at ckendall@ 123456uottawa.ca .

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