Julio Sergio Gonzalez-Montaner

Background: Little is known about the relationship between food insecurity and health outcomes among people living with HIV/AIDS. This dissertation therefore sought to: i) review global evidence regarding the associations between food insecurity and HIV outcomes; ii) assess the prevalence and correlates of food insecurity among HIV-positive individuals receiving antiretroviral therapy (ART) across British Columbia (BC); iii) examine the relationship between hunger and plasma HIV RNA suppression among illicit drug users receiving ART in Vancouver; and iv) investigate the potential impact of food insecurity on mortality among injection drug users (IDU) receiving ART in BC.Methods: Adults receiving ART in three BC-based observational studies completed interviewer-administered surveys eliciting information about socio-demographic profile, risk behavior, and health status, and consenting to database linkage for retrieval of clinical, laboratory and prescription information. Explanatory, confounder and survival models were built to investigate the associations between food insecurity and ART outcomes. Results: A growing body of literature suggests that food insecurity is associated with increased risk of HIV transmission, poor ART access, adherence, pharmacokinetic efficacy, immunologic and virologic response, and reduced survival (Chapter 2). In a sample of 457 individuals receiving ART across BC, food insecurity was reported by 71% and was independently associated with younger age, illicit drug use, low annual income, tobacco smoking and symptoms of depression in explanatory models (Chapter 3). Among 406 illicit drug users receiving ART in Vancouver, 63% reported hunger and 59% had suppressed viral loads. Hunger and virologic suppression were not independently associated in multivariate confounder models (Chapter 4). Among 254 IDU receiving ART across BC, 41% died between June 1998 and September 2011. Food insecurity was associated with a two-fold increased risk of death in adjusted survival models (Chapter 5). Conclusion: This dissertation reviewed current evidence and gaps in knowledge about the relationship between food insecurity and HIV outcomes. Results suggest an urgent need for evidence-based social and structural interventions to reduce food insecurity and associated harms among HIV-infected individuals in BC, particularly among illicit drug users. Public health efforts should consider evaluating the possible role of nutritional supplementation within existing harm reduction and HIV services.

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Background: The objectives of this thesis were to describe the impacts of drug-related street disorder on street-based injection drug users (IDU) in Vancouver, Canada and to explore the potential impacts of three policy interventions (low-threshold supportive housing, low-threshold employment, and supervised inhalation facilities) on the reduction of street disorder. Methods: Data for these studies were derived from the Vancouver Injection Drug Users Study (VIDUS) which is a community recruited prospective cohort of IDU. Study participants were invited on bi-annual bases to complete an interviewer-administered questionnaire. Various multivariate regression techniques were utilized to assess factors associated with exposure to drug-related street disorder, socializing in Vancouver’s open drug scene, engaging in disorderly income generation activities, and smoking crack cocaine in public areas. Further multivariate analyses were conducted to assess willingness to reduce engagement in behaviours that contribute to drug-related street disorder. Results: At baseline, 21% of the study sample reported spending over 15 hour per day in Vancouver’s open drug scene on average. Drug scene exposure was found to be associated in a dose-dependent fashion with higher intensity drug use and multiple markers of vulnerability to adverse health outcomes. In further analyses, 43% of participants reported socializing in the open drug scene for 3 or more hours per day, and having limited access to private space was the factor most strongly associated with this behaviour. Among this group 65% reported being willing to relocate if given access to more private space. 47% of participants who engaged in disorderly income generation activities were willing to forgo these income sources if given low-threshold employment, and 71% of crack cocaine smokers who reported recently using in public areas were willing to visit a supervised inhalation facility.Conclusions: These studies highlight the importance of viewing street disorder in the context of current political, economic, and social conditions and provide a compelling body of evidence indicating that structural and environmental level interventions, specifically in the areas of housing (i.e., provision of private space), employment and supervised drug consumption facilities, are likely to have a positive influence on public health and reduce engagement in drug-related street disorder.

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