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Experiences of Transgender-Related Discrimination and Implications for Health: Results From the Virginia Transgender Health Initiative Study
Objectives. We examined relationships between social determinants of health and experiences of transgender-related discrimination reported by transgender people in Virginia. Methods. In 2005 through 2006, 387 self-identified transgender people completed a statewide health needs assessment; 350 who completed eligibility questions were included in this examination of factors associated with experiences of discrimination in health care, employment, or housing. We fit multivariate logistic regression models using generalized estimating equations to adjust for survey modality (online vs paper). Results. Of participants, 41% (n = 143) reported experiences of transgender-related discrimination. Factors associated with transgender-related discrimination were geographic context, gender (female-to male spectrum vs male-to-female spectrum), low socioeconomic status, being a racial/ethnic minority, not having health insurance, gender transition indicators (younger age at first transgender awareness), health care needed but unable to be obtained (hormone therapy and mental health services), history of violence (sexual and physical), substance use health behaviors (tobacco and alcohol), and interpersonal factors (family support and community connectedness). Conclusions. Findings suggest that transgender Virginians experience widespread discrimination in health care, employment, and housing. Multilevel interventions are needed for transgender populations, including legal protections and training for health care providers.
Journal Article
Chronic disease diagnoses and health service use among people who died of illicit drug toxicity in British Columbia, Canada
Background
Illicit drug toxicity (i.e., overdose) is the leading cause of death in British Columbia (BC) for people aged 10–59. Stimulants are increasingly detected among drug toxicity deaths. As stimulant use and detection in deaths rises, it is important to understand how people who die of stimulant toxicity differ from people who die of opioid toxicity.
Methods
BC Coroners Service records were retrieved for all people who died of unintentional illicit drug toxicity (accidental or undetermined) between January 1, 2015, and December 31, 2019, whose coroner investigation had concluded and who had an opioid and/or stimulant detected in post-mortem toxicology and identified by the coroner as relevant to the death (
N
= 3788). BC Chronic Disease Registry definitions were used to identify people with chronic disease. Multinomial regression models were used to examine the relationship between chronic disease diagnoses and drug toxicity death type.
Results
Of the 3788 deaths, 11.1% (
N
= 422) had stimulants but not opioids deemed relevant to the cause of death (stimulant group), 26.8% (
N
= 1014) had opioids but not stimulants deemed relevant (opioid group), and 62.1% (
N
= 2352) had both opioids and stimulants deemed relevant (opioid/stimulant group). People with ischemic heart disease (1.80 (1.14–2.85)) and people with heart failure (2.29 (1.25–4.20)) had approximately twice the odds of being in the stimulant group as compared to the opioid group.
Conclusions
Findings suggest that people with heart disease who use illicit stimulants face an elevated risk of drug toxicity death. Future research should explore this association and should identify opportunities for targeted interventions to reduce drug toxicity deaths among people with medical comorbidities.
Journal Article
HIV-related outcome disparities between transgender women living with HIV and cisgender people living with HIV served by the Health Resources and Services Administration’s Ryan White HIV/AIDS Program: A retrospective study
In the United States, approximately one-fifth of transgender women are living with HIV-nearly one-half of Black/African American (Black) transgender women are living with HIV. Limited data are available on HIV-related clinical indicators among transgender women. This is because of a lack of robust transgender data collection and research, especially within demographic subgroups. The objective of this study was to examine retention in care and viral suppression among transgender women accessing the Health Resources and Services Administration's (HRSA) Ryan White HIV/AIDS Program (RWHAP)-supported HIV care, compared with cisgender women and cisgender men.
We assessed the association between gender (cisgender or transgender) and (1) retention in care and (2) viral suppression using 2016 client-level RWHAP Services Report data. Multivariable modified Poisson regression models adjusting for confounding by age, race, health care coverage, housing, and poverty level, overall and stratified by race/ethnicity, were used to calculate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs). In 2016, the RWHAP served 6,534 transgender women (79.8% retained in care, 79.0% virally suppressed), 143,173 cisgender women (83.7% retained in care, 84.0% virally suppressed), and 382,591 cisgender men (81.0% retained in care, 85.9% virally suppressed). Black transgender women were less likely to be retained in care than Black cisgender women (aPR: 0.95, 95% CI: 0.92-0.97, p < 0.001). Black transgender women were also less likely to reach viral suppression than Black cisgender women (aPR: 0.55, 95%I CI: 0.41-0.73, p < 0.001) and Black cisgender men (aPR: 0.55, 95% CI: 0.42-0.73, p < 0.001). A limitation of the study is that RWHAP data are collected for administrative, not research, purposes, and clinical outcome measures, including retention and viral suppression, are only reported to the RWHAP for the approximately 60% of RWHAP clients engaged in RWHAP-supported outpatient medical care.
In this study, we observed disparities in HIV clinical outcomes among Black transgender women. These results fill an important gap in national HIV data about transgender people with HIV. Reducing barriers to HIV medical care for transgender women is critical to decrease disparities among this population.
Journal Article
“It’s just a perfect storm”: Exploring the consequences of the COVID-19 pandemic on overdose risk in British Columbia from the perspectives of people who use substances
Background
Despite the implementation and expansion of public health and harm reduction strategies aimed at preventing and reversing overdoses, rates of overdose-related events and fatalities continue to rise in British Columbia. The COVID-19 pandemic created a second, concurrent public health emergency that further exacerbated the illicit drug toxicity crisis, reinforced existing social inequities and vulnerabilities, and highlighted the precariousness of systems in place that are meant to protect the health of communities. By exploring the perspectives of people with recent experience of illicit substance use, this study sought to characterize how the COVID-19 pandemic and associated public health measures influenced risk and protective factors related to unintentional overdose by altering the environment in which people live and use substances, influencing the ability of people who use substances to be safe and well.
Methods
One-on-one semi-structured interviews were conducted by phone or in-person with people who use illicit substances (n = 62) across the province. Thematic analysis was performed to identify factors shaping the overdose risk environment.
Results
Participants pointed to factors that increased risk of overdose, including: [
1
] physical distancing measures that created social and physical isolation and led to more substance use alone without bystanders nearby able to respond in the event of an emergency; [
2
] early drug price spikes and supply chain issues that created inconsistencies in drug availability; [
3
] increasing toxicity and impurities in unregulated substances; [
4
] restriction of harm reduction services and supply distribution sites; and [
5
] additional burden placed on peer workers on the frontlines of the illicit drug toxicity crisis. Despite these challenges, participants highlighted factors that protected against overdose and substance-related harm, including the emergence of new programs, the resiliency of communities of people who use substances who expanded their outreach efforts, the existence of established social relationships, and the ways that individuals consistently prioritized overdose response over concerns about COVID-19 transmission to care for one another.
Conclusions
The findings from this study illustrate the complex contextual factors that shape overdose risk and highlight the importance of ensuring that the needs of people who use substances are addressed in future public health emergency responses.
Journal Article
Awareness and knowledge of drug decriminalization among people who use drugs in British Columbia: a multi-method pre-implementation study
Background
In January 2023, British Columbia implemented a three-year exemption to
Controlled Drugs and Substances Act
, as granted by the federal government of Canada, to decriminalize the personal possession of small amounts of certain illegal drugs. This decriminalization policy, the first in Canada, was announced in response to the overdose emergency in British Columbia as a public health intervention that could help curb overdose deaths by reducing the impact of criminalization and increasing access to health and social services through stigma reduction.
Methods
The current multi-method study examines people who use drugs’ awareness and knowledge of British Columbia’s decriminalization model through cross-sectional quantitative surveys and qualitative interviews among people who use drugs from September–November 2022, immediately prior to the implementation of decriminalization.
Results
Quantitative findings show that two-thirds (63%) of people who use drugs were aware of the policy, but substantial knowledge gaps existed about the legal protections afforded (threshold amount, substances included, drug trafficking, confiscation). The qualitative findings suggest that people who use drugs misunderstood the details of the provincial decriminalization model and often conflated it with regulation. Results suggest that information sharing about decriminalization were minimal pre-implementation, highlighting areas for knowledge dissemination about people who use drugs' rights under this policy.
Conclusions
Given that decriminalization in British Columbia is a new and landmark reform, and that the success of decriminalization and its benefits may be undermined by poor awareness and knowledge of it, efforts to share information, increase understanding, and empower the community, may be required to promote its implementation and benefits for the community.
Journal Article
Smoking identified as preferred mode of opioid safe supply use; investigating correlates of smoking preference through a 2021 cross-sectional study in British Columbia
Background
The increasing number of illicit drug toxicity deaths in British Columbia (BC) has led to calls for a regulated (pharmaceutical grade) supply of substances (“safe supply”). In order to inform safe supply recommendations, we aimed to identify why people currently smoke opioids and assess the preferred mode of consumption if people who use opioids were provided with opioid safe supply.
Methods
The BC Harm Reduction Client Survey (HRCS) is an annual survey that gathers information about people who use drugs' (PWUD) substance use characteristic with the goal of contributing to evidence-based policy. This study utilized data from the 2021 HRCS. The outcome variable was “prefer smoking opioid safe supply” (‘yes/no’). Explanatory variables included participants’ demographics, drug use, and overdose characteristics. Bivariate and hierarchical multivariable logistic regressions were conducted to identify factors associated with the outcome.
Results
Of 282 total participants who indicated a preference for a mode of consumption for opioid safe supply, 62.4% preferred a smokable option and 19.9% preferred to inject if provided with opioid safe supply. Variables significantly associated with the outcome (preferred smoking) included: being 19-29 years old (AOR=5.95, CI =1.93 – 18.31) compared to >50 years old, having witnessed an overdose in the last 6 months (AOR=2.26, CI=1.20 – 4.28), having smoked opioids in the last 3 days (AOR=6.35, CI=2.98 – 13.53) and having a preference to smoke stimulants safe supply (AOR=5.04, CI=2.53 – 10.07).
Conclusion
We found that over half of participants prefer smokable options when accessing opioid safe supply. Currently in BC, there are limited smokable opioid safe supply options as alternatives to the toxic street supply. To reduce overdose deaths, safe supply options should be expanded to accommodate PWUD that prefer smoking opioids.
Journal Article
Feeling safer: effectiveness, feasibility, and acceptability of continuous pulse oximetry for people who smoke opioids at overdose prevention services in British Columbia, Canada
Background
Smoking is the most common mode of unregulated opioid consumption overall and implicated in fatal overdoses in British Columbia (BC). In part, perception of decreased risk (e.g., fewer who smoke carry naloxone kits) and limited smoking-specific harm reduction services contribute to overdose deaths. Overdose prevention services (OPS) offer supervised settings for drug use. Continuous pulse oximetry, common in acute care, allows real-time, remote oxygen monitoring. We evaluated the effectiveness of a novel continuous pulse oximetry protocol aimed at allowing physical distancing (as required by COVID-19, secluded spaces, and to avoid staff exposure to vaporized opioids), its feasibility, and acceptability at OPS for people who smoke opioids.
Methods
This was a mixed methods survey study. We developed a continuous pulse oximetry protocol in collaboration with clinical experts and people with lived/living experience of substance use. We implemented our protocol from March to August 2021 at four OPS in BC permitting smoking. We included adults (≥ 18 years) presenting to OPS to smoke opioids. Peer researchers collected demographic, health, and substance use information, and conducted structured observations. OPS clients participating in our study, OPS staff, and peer researchers completed post-monitoring surveys. We analyzed responses using a thematic inductive approach and validated themes with peer researchers.
Results
We included 599 smoking events. OPS clients participating in our study had a mean age of 38.5 years; 73% were male. Most (98%) reported using “down”, heroin, or fentanyl; 48% concurrently used other substances (32% of whom reported stimulants); 76% reported smoking alone in the last 3 days; and 36% reported an overdose while smoking. Respondents reported that the protocol facilitated physical distancing, was easy to use, high satisfaction, improved confidence, improved sense of safety, and that they would use it again.
Conclusions
Continuous pulse oximetry allowed safe physical distancing, was feasible, and acceptable in monitoring people who smoke opioids at OPS.
Journal Article
The effect of Np-magnetite on the granulation process of an SBR reactor used for domestic wastewater treatment
This study investigated the effect of magnetite nanoparticles (Np-magnetite) added to a pilot-scale sequencing batch reactor (SBR) treating domestic wastewater, to improve aerobic granular sludge (AGS) formation and the effects of granule disintegration. Np-magnetite additions (75 mg L−1) were made during the start-up of the reactor and repeated after 100 and 170 days, when granule disintegration was observed. From the first Np-magnetite addition, SVI5 was reduced from 1315 to 85 mL g−1. The granular biomass was observed on the 56th day, when 57% of the granules presented diameters bigger than 212 µm. The 100-day disintegration episode disturbed the granular biomass, reducing the volatile suspended solids by 51%, increasing the SVI values to above 200 mL g−1. Np-magnetite addition recovered all the granular biomass parameters to the values observed before disintegration. The treatment efficiency was stable during operation of the reactor for nutrients (52.8 ± 23.4% NH4+–N; 54.5 ± 12.2% PO43−–P) and carbonaceous organic matter (71.7 ± 12.7% BOD5; 77.5 ± 10.0% CODt). Np-magnetite addition changed the microbial community of the granular sludge, analysed via high-throughput 16S RNA sequencing, and recovered the treatment efficiency previously disturbed by the disintegration processes. These results indicate the potential of Np-magnetite as an agent for sludge aggregation in an aerobic granular reactor.
Journal Article
“Shared experience makes this all possible”: documenting the guiding principles of peer-led services for people released from prison
Background
There is a growing body of evidence demonstrating the effectiveness of peer-led services in supporting community reintegration for people released from prison. This study aims to document the guiding principle of a peer-led service for people released from prison, from the perspective of peer mentors.
Methods
Data were collected using focus groups (
N
= 10; 2 groups with 5 participants each) and one-on-one interviews (
N
= 5) including a total of 13 people, representing all UTGSS staff at the time of the study. An inductive thematic analysis was used to identify patterns in the data. Initial coding was done by using “in-vivo” codes (i.e. applying codes to terms used by participants). This informed the direction of the next stage of analysis, which focused on identifying categories that synthesized the codes and data across transcripts. In this stage, broad themes and sub-themes were developed.
Findings
Six themes were constructed to reflect the guiding principles of UTGSS staff. This includes four central themes: 1) Offering hope; 2) Building respectful relationships; 3) Providing consistent support; 4) Meeting people where they are at. Two connected themes are also reported: 1)
Relying on shared experience,
which participants reported serves as the foundation for practicing these guiding principles and 2)
Bridging connections to services
, which reflects the outcome of practicing these guiding principles.
Conclusion
The principles identified in this study can be used by UTGSS staff as a guide for checking-in on progress with clients and may be considered as a model for reflection on practice by staff providing similar peer-led services. These principles should not be applied in a prescriptive way, as relationship building is at the centre of peer support, and different applications will be required depending on clients’ goals and the range of supports available within their community.
Journal Article