Martin Schechter

Indigenous scholars have called for responses to substance use and HIV among young Indigenous people that acknowledge ongoing colonization, structural violence, and the impacts of intergenerational traumas, while building on cultural strengths and resilience. This mixed method dissertation took place within The Cedar Project cohort involving young Indigenous people who have used drugs in Vancouver and Prince George, British Columbia (BC). The purpose was to examine experiences of engagement with the HIV cascade of care, and evaluate The Cedar Project WelTel mHealth program for HIV-related health and wellness, among young Indigenous people who have used drugs living in British Columbia, using both qualitative and quantitative approaches. Findings support understanding of how a wholistic perspective of health and wellbeing, as well as experiences of ongoing colonial violence including child apprehension, inform engagement with the HIV cascade of care among Indigenous peoples. Results add to mounting evidence that state-based apprehensions of Indigenous children are a negative determinant of health for Indigenous families. Findings further illustrated how mobile phones can be a tool to support family (re)connections, relationships with health and social services, and self-determination within young Indigenous people who have used drugs’ health and wellness journeys. Moreover, this dissertation demonstrates that a supportive two-way texting mHealth initiative integrated into existing wraparound care from trusted case managers is acceptable and valued by young Indigenous people who have used drugs. Study findings provide evidence that the Cedar Project WelTel mHealth program may be an effective approach to support engagement in HIV care for young Indigenous people who have used drugs, and should be considered for application in other program settings as well. Four overarching recommendations for policy makers and health providers were developed in collaboration with Cedar mentors, committee members, and investigators: (1) uphold a wholistic perspective to walk with young Indigenous people who have used drugs on their health and wellness journeys; (2) urgently address ongoing apprehensions of Indigenous children; (3) offer the Cedar Project WelTel mHealth model for HIV health and wellness; and (4) explore integrating mHealth with healing modalities for substance use and other aspects of wholistic health and wellness.

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Background: Epidemiologists have long noted a paucity of research addressing the role of substance use in conflict and post-conflict settings especially as it interacts with mental health and HIV vulnerability in affected populations. Such is the case in northern Uganda where after two decades of conflict the region is rapidly changing, and where community leaders are expressing concerns as to perceived rapid increases in substance use and its impact on the population and growing HIV epidemic.Methods: This multidisciplinary research explored the intersection of mental health, substance use, and HIV in the context of conflict. This project was conducted in partnership with the “Cango Lyec Project” a five-year cohort project exploring HIV risk among Acholi people aged 14-49 in the Gulu, Nwoya, and Amuru districts of northern Uganda. The quantitative analyses began with a confirmatory factor analysis of the structure and underlying validity of the AUDIT alcohol scale. Next, multivariable regressions explored factors associated with hazardous drinking in the population. Qualitative analyses used an interpretive and interpretive description (ID) thematic approach to analyze 30 in-depth interviews and explored within the context of the quantitative analyses.Results: Quantitative findings indicated strong validity for the AUDIT scale. Overall, rates of drinking were much lower than the rest of Uganda, and women were significantly less likely than men to consume alcohol or have hazardous use behaviors. After adjustment neither post traumatic stress disorder (PTSD), depression, nor HIV were significantly associated with problematic drinking though there were significant associations with many sexual behaviors, and abduction was protective against problematic drinking among men. Qualitative findings highlighted participants’ views that substance use remained a large and growing problem in the region that was closely tied to HIV. Use was highly stigmatized especially as it pertained to perceptions that it constituted a rejection of Acholi traditions.Conclusion: This research highlights the need to integrate rigorous and population-level epidemiological evidence within community perspectives and understandings of risk. While at times the results appeared to contrast, underlying both were clear areas for intervention that acknowledge the profound trauma inflicted by the conflict and areas to support community- driven change.

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Background: Little is known about HIV infection and the related vulnerabilities of young people living in resource-scarce, post-emergency transit camps that are now home to thousands of IDPs following two decades of war in northern Uganda. This population in transition provided a unique opportunity to assess the influence of conflict on HIV infection among young people in post-conflict settings. Methods: In 2010, a cross-sectional demographic and behavioural survey was conducted with a purposively selected sample of 384 transit camp residents aged 15 to 29, in two of Gulu District’s sub-counties. Biological specimens were collected for HIV rapid testing in-field and confirmatory laboratory testing. Multivariable logistic regression identified independent predictors for HIV infection among the sample and stratified by gender. Additionally, a bivariate analysis was conducted comparing HIV risk profiles of former abductees to non-abductees.Results: Of the 384 participants sampled, 192 (50%) were female and 107 (27.9%) were abductees. HIV prevalence was alarmingly high, at 12.8% overall; 15.6% among females; 9.9% among males, and; 12.1% among abductees. Sample sub-groups revealed no significant differences in proportions positive. The strongest predictor of HIV infection among young people was non-consensual sexual debut (Adjusted Odds Ratio [AOR]: 9.88, 95% Confidence Interval [CI]: 1.70, 18.06). Among females, having practiced dry sex was the strongest predictor (AOR: 7.62, 95%CI: 1.56, 16.95), and among males, non-consensual sexual debut was the strongest predictor (AOR: 3.24, 95%CI: 1.37, 7.67). Finally, in bivariate analysis comparing abductees to non-abductees, limited differences in risk profiles were demonstrated.Conclusions: This study sought to fill a lacuna in epidemiological evidence and provide the Ugandan government and NGOs with the data necessary to inform timely and appropriate responses to HIV among young people in post-conflict transition. Study findings serve to recommend a gradual cessation of post-emergency aid and the design of interventions based on well-identified needs rather than circumstantial categorization. Additionally, development of population-specific responses sensitive to local contexts and sufficient to address the underlying causes of complex risk factors influencing the spread of HIV will reach beyond traditional prevention programming in a manner more effectively beneficial to young people in post-conflict settings.

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Background: Opioid dependence is a chronic disease characterized by periods of relapse and remission. Methadone maintenance treatment (MMT) can be effective, though not all patients can be successfully maintained in treatment. Further, treatment entrants often use multiple illicit drugs, a fact whose motive and effect are under-studied. Rigorous evaluation at the aggregate- and patient-level is required to maximize the public health benefits of substance abuse treatment. Objectives: (1) identify the determinants of the time to discontinuation of MMT across multiple treatment episodes; (2) determine the effect of price on drug consumption among polydrug users; (3) identify trends in compliance to MMT dosing guidelines in British Columbia, Canada from 1996-2007; (4) provide a comparative analysis of the psychometric properties of eight measures of health status for opioid users; (5) evaluate differences in trajectories of health status among opioid users following treatment enrolment.Methods: We draw upon longitudinal data collected in administrative databases (study 1 and 3), experimental (study 4 and 5) and observational cohort studies (study 2) to shed light on the life course of treatment and relapse that opioid addicts experience, their decisions to consume addictive substances, and treatment evaluation at the aggregate- and patient-levels.Results: This collection of studies found (1) patients experiencing multiple treatment episodes tended to stay in treatment for progressively longer periods in later episodes; (2) While heroin and crack cocaine were price inelastic polydrug users treated crack cocaine as a substitute for heroin. In terms of treatment evaluation at the aggregate-level, compliance to minimally effective dose guidelines, along with 12-month retention figures have fallen in the past 5 years in British Columbia (study 3). At the patient-level each of the health status measures assessed in the North American Opiate Medication Initiative (NAOMI) trial showed limitations (study 4), however health status can be meaningfully improved through effective, patient-centered opioid substitution treatment (study 5). Conclusions: The results of these novel empirical studies suggest that while MMT can be an effective treatment option for opioid dependence, the individual and program-related factors that limit its effectiveness must be addressed to maximize the public health impact of this treatment.

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