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Exposure to PM2.5 and Blood Lead Level in Two Populations in Ulaanbaatar, Mongolia

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2016-02-15
Abstract: 

Approximately 60% of the households in Ulaanbaatar live in gers (a traditional Mongolian dwelling) in districts outside the legal limits of the city, without access to basic infrastructure, such as water, sewage systems, central heating, and paved roads, in contrast to apartment residents. This stark difference in living conditions creates different public health challenges for Ulaanbaatar residents. Through this research study we aim to test our hypothesis that women living in gers burning coal in traditional stoves for cooking and heating during the winter are exposed to higher concentrations of airborne PM2.5 than women living in apartments in Ulaanbaatar, Mongolia, and this exposure may include exposures to lead in coal with effects on blood lead levels. This cross sectional study recruited a total of 50 women, 40–60 years of age, from these two settings. Air sampling was carried out during peak cooking and heating times, 5:00 p.m.–11:00 p.m., using a direct-reading instrument (TSI SidePak™) and integrated polytetrafluoroethylene (PTFE) filters using the SKC Personal Environmental Monitor. Blood lead level (BLL) was measured using a LeadCare II rapid field test method. In our study population, measured PM2.5 geometric mean (GM) concentrations using the SidePak™ in the apartment group was 31.5 (95% CI:17–99) μg/m3, and 100 (95% CI: 67–187) μg/m3 in ger households (p < 0.001). The GM integrated gravimetric PM2.5 concentrations in the apartment group were 52.8 (95% CI: 39–297) μg/m3 and 127.8 (95% CI: 86–190) μg/m3 in ger households (p = 0.004). The correlation coefficient for the SidePak™ PM2.5 concentrations and filter based PM2.5 concentrations was r = 0.72 (p < 0.001). Blood Lead Levels were not statistically significant different between apartment residents and ger residents (p = 0.15). The BLL is statistically significant different (p = 0.01) when stratified by length of exposures outside of the home. This statistically significant difference in increased BLL could be due to occupational or frequent exposure to other sources of indoor or outdoor air pollution that were not measured. Blood lead levels from our study population are the  study measurements published on women aged 40–60 years of age in Mongolia

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The Problematization of Sexuality among Women Living with HIV and a New Feminist Approach for Understanding and Enhancing Women’s Sexual Lives

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2017-09
Abstract: 

In the context of HIV, women’s sexual rights and sexual autonomy are important but frequently overlooked and violated. Guided by community voices, feminist theories, and qualitative empirical research, we reviewed two decades of global quantitative research on sexuality among women living with HIV. In the 32 studies we found, conducted in 25 countries and composed mostly of cis-gender heterosexual women, sexuality was narrowly constructed as sexual behaviours involving risk (namely, penetration) and physiological dysfunctions relating to HIV illness, with far less attention given to the fullness of sexual lives in context, including more positive and rewarding experiences such as satisfaction and pleasure. Findings suggest that women experience declines in sexual activity, function, satisfaction, and pleasure following HIV diagnosis, at least for some period. The extent of such declines, however, is varied, with numerous contextual forces shaping women’s sexual well-being. Clinical markers of HIV (e.g., viral load, CD4 cell count) poorly predicted sexual outcomes, interrupting widely held assumptions about sexuality for women with HIV. Instead, the effects of HIV-related stigma intersecting with inequities related to trauma, violence, intimate relations, substance use, poverty, aging, and other social and cultural conditions primarily influenced the ways in which women experienced and enacted their sexuality. However, studies framed through a medical lens tended to pathologize outcomes as individual “problems,” whereas others driven by a public health agenda remained primarily preoccupied with protecting the public from HIV. In light of these findings, we present a new feminist approach for research, policy, and practice toward understanding and enhancing women’s sexual lives—one that affirms sexual diversity; engages deeply with society, politics, and history; and is grounded in women’s sexual rights.

Document type: 
Article

“I Always Worry about What Might Happen Ahead”: Implementing Safer Conception Services in the Current Environment of Reproductive Counseling for HIV-Affected Men and Women in Uganda

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2016-01
Abstract: 

We explored healthcare provider perspectives and practices regarding safer conception counseling for HIV-affected clients. Methods. We conducted semistructured interviews with 38 providers (medical and clinical officers, nurses, peer counselors, and village health workers) delivering care to HIV-infected clients across 5 healthcare centres in Mbarara District, Uganda. Interview transcripts were analyzed using content analysis. Results. Of 38 providers, 76% were women with median age 34 years (range 24–57). First, we discuss providers' reproductive counseling practices. Emergent themes include that providers (1) assess reproductive goals of HIV-infected female clients frequently, but infrequently for male clients; (2) offer counseling focused on "family planning" and maternal and child health; (3) empathize with the importance of having children for HIV-affected clients; and (4) describe opportunities to counsel HIV-serodiscordant couples. Second, we discuss provider-level challenges that impede safer conception counseling. Emergent themes included the following: (1) providers struggle to translate reproductive rights language into individualized risk reduction given concerns about maternal health and HIV transmission and (2) providers lack safer conception training and support needed to provide counseling. Discussion. Tailored guidelines and training are required for providers to implement safer conception counseling. Such support must respond to provider experiences with adverse HIV-related maternal and child outcomes and a national emphasis on pregnancy prevention.

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Does Size Really Matter? A Sensitivity Analysis of Number of Seeds in a Respondent-Driven Sampling Study of Gay, Bisexual and Other Men Who Have Sex With Men in Vancouver, Canada

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2016-11-16
Abstract: 

Background Respondent-driven sampling (RDS) is an increasingly used peer chain-recruitment method to sample “hard-to-reach” populations for whom there are no reliable sampling frames. Implementation success of RDS varies; one potential negative factor being the number of seeds used. Methods We conducted a sensitivity analysis on estimates produced using data from an RDS study of gay, bisexual and other men who have sex with men (GBMSM) aged ≥16 years living in Vancouver, Canada. Participants completed a questionnaire on demographics, sexual behavior and substance use. For analysis, we used increasing seed exclusion criteria, starting with all participants and subsequently removing unproductive seeds, chains of ≤1 recruitment waves, and chains of ≤2 recruitment waves. We calculated estimates for three different outcomes (HIV serostatus, condomless anal intercourse with HIV discordant/unknown status partner, and injecting drugs) using three different RDS weighting procedures: RDS-I, RDS-II, and RDS-SS. We also assessed seed dependence with bottleneck analyses and convergence plots. Statistical differences between RDS estimators were assessed through simulation analysis. Results Overall, 719 participants were recruited, which included 119 seeds and a maximum of 16 recruitment waves (mean chain length = 1.7). The sample of   >0 recruitment waves removed unproductive seeds (n = 50/119, 42.0%), resulting in 69 chains (mean length = 3.0). The sample of >1 recruitment waves removed 125 seeds or recruits (17.4% of overall sample), resulting in 37 chains (mean length = 4.8). The final sample of >2 recruitment waves removed a further 182 seeds or recruits (25.3% of overall sample), resulting in 25 chains (mean length = 6.1). Convergence plots and bottleneck analyses of condomless anal intercourse with HIV discordant/unknown status partner and injecting drugs outcomes were satisfactory. For these two outcomes, regardless of seed exclusion criteria used, the crude proportions fell within 95% confidence intervals of all RDS-weighted estimates. Significant differences between the three RDS estimators were not observed. Conclusions Within a sample of GBMSM in Vancouver, Canada, this RDS study suggests that when equilibrium and homophily are met, although potentially costly and time consuming, analysis is not negatively affected by large numbers of unproductive or lowly productive seeds.

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An Integrated Approach to Care Attracts People Living with HIV who Use Illicit Drugs in an Urban Centre with a Concentrated HIV Epidemic

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2016-11-22
Abstract: 

Background People living with HIV (PLHIV) who are also marginalized by social and structural inequities often face barriers to accessing and adhering to HIV treatment and care. The Dr. Peter Centre (DPC) is a non-profit integrated care facility with a supervised injection room that serves PLHIV experiencing multiple barriers to social and health services in Vancouver, Canada. This study examines whether the DPC is successful in drawing in PLHIV with complex health issues, including addiction. Methods Using data collected by the Longitudinal Investigations into Supportive and Ancillary health services (LISA) study from July 2007 to January 2010, linked with clinical variables available through the British Columbia Centre for Excellence in HIV/AIDS Drug Treatment Program, we identified DPC and non-DPC clients with a history of injection drug use. Bivariable and multivariable logistic regression analyses compared socio-demographic and clinical characteristics of DPC clients (n = 76) and non-DPC clients (n = 482) with a history of injection drug use. Results Of the 917 LISA participants included within this analysis, 100 (10.9%) reported being a DPC client, of which 76 reported a history of injection drug use. Adjusted results found that compared to non-DPC clients with a history of injection drug use, DPC-clients were more likely to be male (AOR: 4.18, 95% CI = 2.09–8.37); use supportive services daily vs. less than daily (AOR: 3.16, 95% CI = 1.79–5.61); to have been diagnosed with a mental health disorder (AOR: 2.11; 95% CI: 1.12–3.99); to have a history of interpersonal violence (AOR: 2.76; 95% CI: 1.23–6.19); and to have ever experienced ART interruption longer than 1 year (AOR: 2.39; 95% CI: 1.38–4.15). Conclusions Our analyses suggest that the DPC operating care model engages PLHIV with complex care needs, highlighting that integrated care facilities are needed to support the multiple intersecting vulnerabilities faced by PLHIV with a history of injection drug use living within urban centres in North America and beyond.

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Prevalence, Type, and Correlates of Trauma Exposure Among Adolescent Men and Women in Soweto, South Africa: Implications for HIV Prevention

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2016-11-25
Abstract: 

BACKGROUND: Youth trauma exposure is associated with syndemic HIV risk. We measured lifetime prevalence, type, and correlates of trauma experience by gender among adolescents living in the HIV hyper-endemic setting of Soweto, South Africa. METHODS: Using data from the Botsha Bophelo Adolescent Health Survey (BBAHS), prevalence of "ever" experiencing a traumatic event among adolescents (aged 14-19) was assessed using a modified Traumatic Event Screening Inventory-Child (TESI-C) scale (19 items, study alpha = 0.63). We assessed self-reported number of potentially traumatic events (PTEs) experienced overall and by gender. Gender-stratified multivariable logistic regression models assessed independent correlates of 'high PTE score' (≥7 PTEs). RESULTS: Overall, 767/830 (92%) participants were included (58% adolescent women). Nearly all (99.7%) reported experiencing at least one PTE. Median PTE was 7 [Q1,Q3: 5-9], with no gender differences (p = 0.19). Adolescent men reported more violent PTEs (e.g., "seen an act of violence in the community") whereas women reported more non-violent HIV/AIDS-related PTEs (e.g., "family member or someone close died of HIV/AIDS"). High PTE score was independently associated with high food insecurity among adolescent men and women (aOR = 2.63, 95%CI = 1.36-5.09; aOR = 2.57, 95%CI = 1.55-4.26, respectively). For men, high PTE score was also associated with older age (aOR = 1.40/year, 95%CI = 1.21-1.63); and recently moving to Soweto (aOR = 2.78, 95%CI = 1.14-6.76). Among women, high PTE score was associated with depression using the CES-D scale (aOR = 2.00, 95%CI = 1.31-3.03,) and inconsistent condom use vs. no sexual experience (aOR = 2.69, 95%CI = 1.66-4.37). CONCLUSION: Nearly all adolescents in this study experienced trauma, with gendered differences in PTE types and correlates, but not prevalence. Exposure to PTEs were distributed along social and gendered axes. Among adolescent women, associations with depression and inconsistent condom use suggest pathways for HIV risk. HIV prevention interventions targeting adolescents must address the syndemics of trauma and HIV through the scale-up of gender-transformative, youth-centred, trauma-informed integrated HIV and mental health services.

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Changes in Mortality Rates and Causes of Death in a Population-Based Cohort of Persons Living With and Without HIV from 1996 to 2012

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2017-02
Abstract: 

BACKGROUND: Non-HIV/AIDS-related diseases are gaining prominence as important causes of morbidity and mortality among people living with HIV. The purpose of this study was to characterize and compare changes over time in mortality rates and causes of death among a population-based cohort of persons living with and without HIV in British Columbia (BC), Canada. METHODS: We analysed data from the Comparative Outcomes And Service Utilization Trends (COAST) study; a retrospective population-based study created via linkage between the BC Centre for Excellence in HIV/AIDS and Population Data BC, and containing data for HIV-infected individuals and the general population of BC, respectively. Our analysis included all known HIV-infected adults (≥ 20 years) in BC and a random 10% sample of uninfected BC adults followed from 1996 to 2012. Deaths were identified through Population Data BC - which contains information on all registered deaths in BC (BC Vital Statistics Agency dataset) and classified into cause of death categories using International Classification of Diseases (ICD) 9/10 codes. Age-standardized mortality rates (ASMR) and mortality rate ratios were calculated. Trend test were performed. RESULTS: 3401 (25%), and 47,647 (9%) individuals died during the 5,620,150 person-years of follow-up among 13,729 HIV-infected and 510,313 uninfected individuals, respectively. All-cause and cause-specific mortality rates were consistently higher among HIV-infected compared to HIV-negative individuals, except for neurological disorders. All-cause ASMR decreased from 126.75 (95% CI: 84.92-168.57) per 1000 population in 1996 to 21.29 (95% CI: 17.79-24.79) in 2011-2012 (83% decline; p < 0.001 for trend), compared to a change from 7.97 (95% CI: 7.61-8.33) to 6.87 (95% CI: 6.70-7.04) among uninfected individuals (14% decline; p < 0.001). Mortality rates from HIV/AIDS-related causes decreased by 94% from 103.85 per 1000 population in 1996 to 6.72 by the 2011-2012 era (p < 0.001). Significant ASMR reductions were also observed for hepatic/liver disease and drug abuse/overdose deaths. ASMRs for neurological disorders increased significantly over time. Non-AIDS-defining cancers are currently the leading non-HIV/AIDS-related cause of death in both HIV-infected and uninfected individuals. CONCLUSIONS: Despite the significant mortality rate reductions observed among HIV-infected individuals from 1996 to 2012, they still have excess mortality risk compared to uninfected individuals. Additional efforts are needed to promote effective risk factor management and appropriate screening measures among people living with HIV.

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Validating a Self-Report Measure of HIV Viral Suppression: An Analysis of Linked Questionnaire and Clinical Data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2017-03
Abstract: 

BACKGROUND: We assessed the validity of a self-report measure of undetectable viral load (VL) among women with HIV in British Columbia (BC), Canada. Questionnaire data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study was linked with population-based clinical data from the BC Centre for Excellence in HIV/AIDS. Self-reported undetectable VL was assessed by the question: "What was your most recent VL, undetectable (i.e. <50 copies/mL) or detectable (i.e. ≥50 copies/mL)?" Laboratory measurements of VL <50 copies/mL (closest to/before study visit) were the criterion for validity analyses. We measured positive and negative predictive values (PPV, NPV) and likelihood ratios (LR+, LR-). RESULTS: Of 356 participants, 99% were linked to clinical data. Those unlinked (n = 1), missing self-report VL (n = 18), or missing self-report and laboratory VL (n = 1) were excluded. Among the remaining 336: median age was 44 (IQR 37-51); 96% identified as cis-gender; 84% identified as heterosexual; and 45% identified as Indigenous, 40% White, 8% African, Caribbean, or Black, and 8% other/multiple ethnicities. Overall, 85% self-reported having an undetectable VL while 82% had clinical data indicating viral suppression. The PPV was 93.7 (95% CI 90.2-96.2) indicating that 94% of women who self-reported being undetectable truly were. The NPV was 80.4 (95% CI 66.9-90.2). LR+ was 3.2 (2.1-4.6) and LR- was 0.05 (0.03-0.10). CONCLUSIONS: Our self-report measure assessing undetectable VL strongly predicted true viral suppression among Canadian women with HIV. This measure can be used in research settings without laboratory data in regions with high rates of VL testing and suppression.

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Conspiracy Beliefs and Knowledge About HIV Origins Among Adolescents in Soweto, South Africa

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2017-02-02
Abstract: 

We examined adolescents' knowledge regarding the origin of HIV/AIDS and correlates of beliefs surrounding conspiracy theories in Soweto, South Africa. Now, a decade post-AIDS denialism, South Africa has the largest antiretroviral therapy roll-out worldwide. However, conspiracy theories stemming from past AIDS denialism may impact HIV prevention and treatment efforts.

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Global Health Governance: We Need Innovation not Renovation

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2017-03-09
Abstract: 

Although the global health community widely accepts that WHO, as currently configured, is no longer fit-for-purpose, commentators cling to renovation (‘reform’), rather than innovation, at the expense of a global health governance system that reflects the needs of a very changed world.Collective action in a globalised world requires institutions that look very different from what we currently have. Rather than the renovation of outdated institutional forms—which are closed, territorially fixed and hierarchical—we need to harness innovations such as social networks, open-source systems and the sharing economy.One of the biggest forms of institutional innovation more broadly is ‘network governance’, by which collective action is achieved through interconnected institutions spanning government, business and civil society.

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