Mel Krajden

University of British Columbia - Vancouver, Vancouver, British Columbia, Canada

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Publications (165)655.61 Total impact

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    ABSTRACT: In light of accumulated scientific evidence of the secondary preventive benefits of antiretroviral therapy, a growing number of jurisdictions worldwide have formally started to implement HIV Treatment as Prevention (TasP) programs. To date, no gold standard for TasP program monitoring has been described. Here, we describe the design and methods applied to TasP program process monitoring in British Columbia (BC), Canada.
    Journal of acquired immune deficiency syndromes (1999). 07/2014;
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    ABSTRACT: Failure to understand the risk of false negative HIV test results during the window period results in anxiety. Patients typically want accurate test results as soon as possible while clinicians prefer to wait until the probability of a false negative is virtually nil. This review summarizes the median window periods for third-generation antibody and fourth-generation HIV tests and provides the probability of a false negative result for various days post-exposure.
    International Journal of STD & AIDS 07/2014; · 1.00 Impact Factor
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    ABSTRACT: Little is known about factors associated with HCV transmission among people who inject drugs (PWID). Phylogenetic clustering and associated factors were evaluated among PWID in Vancouver, Canada. Data were derived from the Vancouver Injection Drug Users Study. Participants who were HCV antibody positive at enrolment and those with HCV antibody seroconversion during follow-up (1996 to 2012) were tested for HCV RNA and sequenced (Core-E2 region). Phylogenetic trees were inferred using maximum likelihood analysis and clusters were identified using ClusterPicker (90% bootstrap threshold, 0.05 genetic distance threshold). Factors associated with clustering were assessed using logistic regression. Among 655 eligible participants, HCV genotype prevalence was: G1a: 48% (n=313), G1b: 6% (n=41), G2a: 3% (n=20), G2b: 7% (n=46), G3a: 33% (n=213), G4a: <1% (n=4), G6a: 1% (n=8), G6e: <1% (n=1) and unclassifiable: 1% (n=9). The mean age was 36 years, 162 (25%) were female and 164 (25%) were HIV+. Among 501 participants with HCV G1a and G3a, 31% (n=156) were in a pair/cluster. Factors independently associated with phylogenetic clustering included: age <40 (vs. age ≥40, adjusted odds ratio [AOR] = 1.64; 95% CI 1.03, 2.63), HIV infection (AOR = 1.82; 95% CI 1.18, 2.81), HCV seroconversion (AOR = 3.05; 95% CI 1.40, 6.66) and recent syringe borrowing (AOR 1.59; 95% CI 1.07, 2.36). Conclusion: In this sample of PWID, one-third demonstrated phylogenetic clustering. Factors independently associated with phylogenetic clustering included younger age, recent HCV seroconversion, prevalent HIV infection, and recent syringe borrowing. Strategies to enhance the delivery of prevention and/or treatment strategies to those with HIV and recent HCV seroconversion should be explored, given an increased likelihood of HCV transmission in these sub-populations.3 (Hepatology 2014;)
    Hepatology 07/2014; · 12.00 Impact Factor
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    ABSTRACT: To understand A(H1N1)pdm09 epidemic resurgence during the 2013-14 influenza season, we compared age-related cross-sectional estimates of sero-protection pre-pandemic (2009) and post-pandemic (2010 and 2013) to subsequent surveillance-based laboratory-confirmed A(H1N1)pdm09 incidence in British Columbia, Canada. Pre-pandemic sero-protection was negligible except among the very old ³80 years (80%). Conversely, post-pandemic sero-protection followed a U-shaped distribution: ∼35-45% among working-age adults but ³70% in the very old and young children, excluding children <5years in 2013 for whom sero-protection again fell below 20%. Incidence was 5-fold higher in 2013-14 than 2010-11, highest in preschool-aged children and working-age adults, following a mirror-image of sero-protection by age.
    The Journal of infectious diseases. 06/2014;
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    ABSTRACT: Objective: Test uptake and case detection trends for rubella, syphilis, HIV, and hepatitis C (HCV) were compared among the 2007 to 2011 cohort of women undergoing prenatal testing in British Columbia. Analysis involved linkage of provincially centralized laboratory and surveillance data to assess prenatal test uptake and rates of newly diagnosed versus prevalent infections. Methods: We included prenatal specimens submitted from BC women aged 16 to 45 years in 2007 to 2011. Laboratory records were linked to provincial surveillance systems to identify confirmed maternal syphilis and HIV cases. Previous positive status was determined for HIV and HCV if a prior confirmed case was identified from laboratory records. We determined rates of HIV and HCV newly identified at prenatal screening (new diagnoses per 100 000 per year). Prevalence for HIV and HCV was the sum of all new and prior diagnoses (prevalence per 100 000 per year). Results: Of 233 203 women, 96.9% were screened for rubella, 93.3% for syphilis, 93.8% for HIV, and 21.5% for HCV. From 2007 to 2011, the overall rates of new diagnoses were 15.4, 5.1, and 82.8 cases per 100 000 per year for syphilis, HIV, and HCV, respectively. The overall prevalence was 45.9 and 551.5 cases per 100 000 per year for HIV and HCV, respectively (0.05% and 0.6%). From 2007 to 2011, new diagnoses of HCV decreased 40% from 106.0 to 62.1 cases per 100 000 per year. HCV prevalence did not change and increased with maternal age. Conclusion: This study links surveillance and laboratory data to provide a provincial picture of prenatal screening test uptake and case detection, with the advantage of distinguishing new from prior diagnoses. This information can help guide prenatal communicable disease screening policy.
    06/2014; 36(6):482-490.
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    ABSTRACT: The disease burden of hepatitis C virus (HCV) is expected to increase as the infected population ages. A modelling approach was used to estimate the total number of viremic infections, diagnosed, treated and new infections in 2013. In addition, the model was used to estimate the change in the total number of HCV infections, the disease progression and mortality in 2013-2030. Finally, expert panel consensus was used to capture current treatment practices in each country. Using today's treatment paradigm, the total number of HCV infections is projected to decline or remain flat in all countries studied. However, in the same time period, the number of individuals with late-stage liver disease is projected to increase. This study concluded that the current treatment rate and efficacy are not sufficient to manage the disease burden of HCV. Thus, alternative strategies are required to keep the number of HCV individuals with advanced liver disease and liver-related deaths from increasing.
    Journal of Viral Hepatitis 05/2014; 21 Suppl 1:34-59. · 3.08 Impact Factor
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    ABSTRACT: Chronic infection with hepatitis C virus (HCV) is a major cause of cirrhosis, hepatocellular carcinoma and liver transplantation.
    Canadian journal of gastroenterology & hepatology. 05/2014; 28(5):243-50.
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    ABSTRACT: Chronic infection with hepatitis C virus (HCV) is a leading indicator for liver disease. New treatment options are becoming available, and there is a need to characterize the epidemiology and disease burden of HCV. Data for prevalence, viremia, genotype, diagnosis and treatment were obtained through literature searches and expert consensus for 16 countries. For some countries, data from centralized registries were used to estimate diagnosis and treatment rates. Data for the number of liver transplants and the proportion attributable to HCV were obtained from centralized databases. Viremic prevalence estimates varied widely between countries, ranging from 0.3% in Austria, England and Germany to 8.5% in Egypt. The largest viremic populations were in Egypt, with 6 358 000 cases in 2008 and Brazil with 2 106 000 cases in 2007. The age distribution of cases differed between countries. In most countries, prevalence rates were higher among males, reflecting higher rates of injection drug use. Diagnosis, treatment and transplant levels also differed considerably between countries. Reliable estimates characterizing HCV-infected populations are critical for addressing HCV-related morbidity and mortality. There is a need to quantify the burden of chronic HCV infection at the national level.
    Journal of Viral Hepatitis 05/2014; 21 Suppl 1:5-33. · 3.08 Impact Factor
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    ABSTRACT: The number of hepatitis C virus (HCV) infections is projected to decline while those with advanced liver disease will increase. A modeling approach was used to forecast two treatment scenarios: (i) the impact of increased treatment efficacy while keeping the number of treated patients constant and (ii) increasing efficacy and treatment rate. This analysis suggests that successful diagnosis and treatment of a small proportion of patients can contribute significantly to the reduction of disease burden in the countries studied. The largest reduction in HCV-related morbidity and mortality occurs when increased treatment is combined with higher efficacy therapies, generally in combination with increased diagnosis. With a treatment rate of approximately 10%, this analysis suggests it is possible to achieve elimination of HCV (defined as a >90% decline in total infections by 2030). However, for most countries presented, this will require a 3-5 fold increase in diagnosis and/or treatment. Thus, building the public health and clinical provider capacity for improved diagnosis and treatment will be critical.
    Journal of Viral Hepatitis 05/2014; 21 Suppl 1:60-89. · 3.08 Impact Factor
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    ABSTRACT: Background. We estimate vaccine effectiveness (VE) against both influenza A/subtypes and B/lineages in Canada for the 2011-12 trivalent inactivated influenza vaccine (TIV) with components entirely unchanged from 2010-11 and in the context of phenotypic and genotypic characterization of circulating viruses.Methods. In a test-negative case-control study VE was estimated as [1-adjustedOddsRatio]X100 for RT-PCR-confirmed influenza in vaccinated versus non-vaccinated participants. Viruses were characterized by hemagglutination-inhibition (HI) and sequencing of antigenic sites of the hemagglutinin (HA) gene.Results. There were 1507 participants. VE against A(H1N1)pdm09 was 80%(95%CI:52-92%): circulating viruses were HI-characterized as vaccine-matched and bore just 2 amino-acid (AA) differences from vaccine. VE against A/H3N2 was 51%(95%CI:10-73%): circulating viruses were HI-characterized as vaccine-related but bore ≥11AA differences from vaccine. VE against influenza/B was 51%(95%CI:26-67%): 71%(95%CI:40-86%) for lineage-matched B/Victoria and 27%(95%CI-21-56%) for lineage-mismatched B/Yamagata. For both influenza A and B types, VE was similar among recipients of either 2010-11 or 2011-12 TIV alone, higher when vaccinated both seasons.Conclusions. Phenotypic and genotypic characterization of circulating and vaccine viruses enhances understanding of TIV performance, shown in 2011-12 to be substantial against well-conserved A(H1N1)pdm09 and lineage-matched influenza/B, suboptimal against genetic-variants of A/H3N2 and further reduced against lineage-mismatched influenza/B. With unchanged vaccine components, protection may extend beyond a single season.
    The Journal of Infectious Diseases 01/2014; · 5.85 Impact Factor
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    ABSTRACT: People who inject drugs (PWID) are at high risk of hepatitis C virus (HCV) infection. Trends in HCV incidence and associated risk factors among PWID recruited between 1996 and 2012 in Vancouver, Canada were evaluated.
    PLoS ONE 01/2014; 9(6):e97726. · 3.73 Impact Factor
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    ABSTRACT: Background & Aims People living with hepatitis C virus (HCV) are at increased risk of all-cause and liver-related mortality, although successful treatment has been shown to reduce this risk. The aim of this study was to provide baseline data on trends in cause-specific mortality, and establish an international surveillance system for evaluating the population level impact of HCV treatments. Methods Population level HCV diagnosis databases from Scotland (1997-2010), Australia (New South Wales [NSW]) (1997-2006), and Canada (British Columbia [BC]) (1997-2003) were linked to corresponding death registries using record linkage. For each region, age-adjusted cause-specific mortality rates were calculated, and trends in annual age-adjusted liver-related mortality were plotted. Results Of 105,138 individuals diagnosed with HCV (21,810 in Scotland, 58,484 in NSW, and 24,844 in BC), there were 7,275 deaths (2,572 in Scotland, 2,655 in NSW, and 2,048 in BC). Liver-related deaths accounted for 26% of deaths in Scotland, 21% in NSW, and 22% in BC. Temporal trends in age-adjusted liver related mortality were stable in Scotland (males p=0.4; females p=0.2) and NSW (males p=0.9; females p=0.9), while there was an increase in BC (males p=0.002; females p=0.04). Conclusions The risk of liver-related mortality after a diagnosis of HCV has remained stable or increased over time across three regions with well-established diagnosis databases, highlighting that HCV treatment programmes to-date have had minimal impact on population level HCV-related liver disease. With more effective therapies on the horizon, and greater uptake of treatment anticipated, the potential of future therapeutic strategies to reduce HCV-related mortality is considerable.
    Journal of Hepatology. 01/2014;
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    ABSTRACT: There has been renewed call for the global expansion of highly active antiretroviral therapy (HAART) under the framework of HIV treatment as prevention (TasP). However, population-level sustainability of this strategy has not been characterized. We used population-level longitudinal data from province-wide registries including plasma viral load, CD4 count, drug resistance, HAART use, HIV diagnoses, AIDS incidence, and HIV-related mortality. We fitted two Poisson regression models over the study period, to relate estimated HIV incidence and the number of individuals on HAART and the percentage of virologically suppressed individuals. HAART coverage, median pre-HAART CD4 count, and HAART adherence increased over time and were associated with increasing virological suppression and decreasing drug resistance. AIDS incidence decreased from 6.9 to 1.4 per 100,000 population (80% decrease, p = 0.0330) and HIV-related mortality decreased from 6.5 to 1.3 per 100,000 population (80% decrease, p = 0.0115). New HIV diagnoses declined from 702 to 238 cases (66% decrease; p = 0.0004) with a consequent estimated decline in HIV incident cases from 632 to 368 cases per year (42% decrease; p = 0.0003). Finally, our models suggested that for each increase of 100 individuals on HAART, the estimated HIV incidence decreased 1.2% and for every 1% increase in the number of individuals suppressed on HAART, the estimated HIV incidence also decreased by 1%. Our results show that HAART expansion between 1996 and 2012 in BC was associated with a sustained and profound population-level decrease in morbidity, mortality and HIV transmission. Our findings support the long-term effectiveness and sustainability of HIV treatment as prevention within an adequately resourced environment with no financial barriers to diagnosis, medical care or antiretroviral drugs. The 2013 Consolidated World Health Organization Antiretroviral Therapy Guidelines offer a unique opportunity to further evaluate TasP in other settings, particularly within generalized epidemics, and resource-limited setting, as advocated by UNAIDS.
    PLoS ONE 01/2014; 9(2):e87872. · 3.73 Impact Factor
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    ABSTRACT: Objectives We compared a 3rd generation (gen) and two 4th gen HIV enzyme immunoassays (EIAs) to pooled nucleic acid testing (PNAT) for the identification of pre- and early seroconversion acute HIV infection (AHI). Study design 9550 specimens from males >18 years from clinics attended by men who have sex with men were tested by Siemens ADVIA Centaur® HIV 1/O/2 (3rd gen) and HIV Combo (4th gen), as well as by Abbott ARCHITECT® HIV Ag/Ab Combo (4th gen). Third gen non-reactive specimens were also tested by Roche COBAS® Ampliprep/COBAS® TaqMan HIV-1 Test v.2 in pools of 24 samples. Sensitivity and specificity of the three EIAs for AHI detection were compared. Results 7348 persons contributed 9435 specimens and had no evidence of HIV infection, 79 (94 specimens) had established HIV infection, 6 (9 specimens) had pre-seroconversion AHI and 9 (12 specimens) had early seroconversion AHI. Pre-seroconversion AHI cases were not detected by 3rd gen EIA, whereas 2/6 (33.3%) were detected by Siemens 4th gen, 4/6 (66.7%) by Abbott 4th gen and 6/6 (100%) by PNAT. All three EIAs and PNAT detected all individuals with early seroconversion AHI. Overall sensitivity/specificity for the EIAs relative to WB or NAT resolved infection status was 93.6%/99.9% for Siemens 3rd gen, 95.7%/99.7% for Siemens 4th gen and 97.9%/99.2% for Abbott 4th gen. Conclusions While both 4th gen EIAs demonstrated improved sensitivity for AHI compared to 3rd gen EIA, PNAT identified more AHI cases than either 4th gen assay. PNAT is likely to remain a useful strategy to identify AHI in high-risk populations.
    Journal of Clinical Virology. 01/2014;
  • Euro surveillance: bulletin europeen sur les maladies transmissibles = European communicable disease bulletin 01/2014; 19(5). · 5.49 Impact Factor
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    ABSTRACT: Influenza vaccine effectiveness (VE) is generally interpreted in the context of vaccine match/mismatch to circulating strains with evolutionary drift in the latter invoked to explain reduced protection. During the 2012-13 season, however, detailed genotypic and phenotypic characterization shows that low VE was instead related to mutations in the egg-adapted H3N2 vaccine strain rather than antigenic drift in circulating viruses. Component-specific VE against medically-attended, PCR-confirmed influenza was estimated in Canada by test-negative case-control design. Influenza A viruses were characterized genotypically by amino acid (AA) sequencing of established haemagglutinin (HA) antigenic sites and phenotypically through haemagglutination inhibition (HI) assay. H3N2 viruses were characterized in relation to the WHO-recommended, cell-passaged vaccine prototype (A/Victoria/361/2011) as well as the egg-adapted strain as per actually used in vaccine production. Among the total of 1501 participants, influenza virus was detected in 652 (43%). Nearly two-thirds of viruses typed/subtyped were A(H3N2) (394/626; 63%); the remainder were A(H1N1)pdm09 (79/626; 13%), B/Yamagata (98/626; 16%) or B/Victoria (54/626; 9%). Suboptimal VE of 50% (95%CI: 33-63%) overall was driven by predominant H3N2 activity for which VE was 41% (95%CI: 17-59%). All H3N2 field isolates were HI-characterized as well-matched to the WHO-recommended A/Victoria/361/2011 prototype whereas all but one were antigenically distinct from the egg-adapted strain as per actually used in vaccine production. The egg-adapted strain was itself antigenically distinct from the WHO-recommended prototype, and bore three AA mutations at antigenic sites B [H156Q, G186V] and D [S219Y]. Conversely, circulating viruses were identical to the WHO-recommended prototype at these positions with other genetic variation that did not affect antigenicity. VE was 59% (95%CI:16-80%) against A(H1N1)pdm09, 67% (95%CI: 30-85%) against B/Yamagata (vaccine-lineage) and 75% (95%CI: 29-91%) against B/Victoria (non-vaccine-lineage) viruses. These findings underscore the need to monitor vaccine viruses as well as circulating strains to explain vaccine performance. Evolutionary drift in circulating viruses cannot be regulated, but influential mutations introduced as part of egg-based vaccine production may be amenable to improvements.
    PLoS ONE 01/2014; 9(3):e92153. · 3.73 Impact Factor
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    ABSTRACT: Canadian surveys of men who have sex with men (MSM) and people using injection drugs (IDU) demonstrate that most have tested for HIV at least once, but that half or fewer have done so in the previous year. To better inform targeted HIV testing guidelines for these populations, we derived estimates of inter-test interval (ITI) for persons newly diagnosed with HIV in British Columbia (BC) between 2006 and 2011, and assessed variables associated with longer ITI among MSM and IDU. Provincial HIV case report and testing data were linked by deterministic and probabilistic matching (based on unique personal health number, name, and date of birth). ITI was defined as time from last recorded negative to first positive HIV result; those with ITI ≤30 days were excluded. Of 2,004 eligible individuals, 1,116 (55.7%) had a recorded negative HIV test result in the previous ten years. Overall median ITI was 20 months with a skewed distribution (inter-quartile range 8-46); median ITI was 15 months for MSM and 21 months for IDU with 41.2% and 33.1% testing in the past year, respectively. Longer ITI was associated with older age for both groups, and among MSM with residence outside Vancouver and not known to have an HIV-positive partner. These findings highlight potential missed opportunities for earlier detection of HIV and prevention of secondary transmission among newly diagnosed MSM and IDU, and provide evidence to inform recommendations for HIV test frequency and testing strategies for these populations in BC.
    Canadian journal of public health = Revue canadienne de santé publique. 01/2014; 105(1):e63-8.
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    ABSTRACT: Human papillomavirus (HPV) vaccination is routinely recommended in HIV-positive men who have sex with men (MSM) aged ≤26 years. Levels of previous HPV exposure in older HIV-positive MSM are assumed to be too high to warrant routine HPV vaccination. However, little is known about the prevalence of and risk factors for neutralizing antibody seropositivity to HPV-16 or HPV-18, a key measure of previous exposure to these types. Cross-sectional analysis of baseline visit for 296 HIV-positive MSM participating in a prospective cohort study of anal squamous intraepithelial lesions at a university-based research clinic. Participants completed a questionnaire detailing behaviors and medical history. Phlebotomy, anal cytology, HPV DNA testing with quantitation, and high-resolution anoscopy with biopsy were performed. A pseudovirion-based neutralizing antibody assay was used to measure HPV-16 and HPV-18 neutralizing antibodies. One hundred thirty-two of 296 (45%) men were HPV-16 seropositive and 141 of 296 (48%) were HPV-18 seropositive. One hundred seventy-five of 296 (59%) of the men were positive for HPV-16 antibodies or DNA and 167 of 296 (56%) were positive for HPV-18 antibodies or DNA. In multivariable analysis, HPV-16 seropositivity did not correlate with age, years of HIV positivity, CD4 level, or HIV viral load. Significant risk factors included HPV-16 DNA positivity with higher DNA levels (ptrend < 0.001) and higher number of receptive sexual partners in the last year (ptrend = 0.012). A high proportion of HIV-positive MSM aged >26 years are DNA negative and seronegative to HPV-16 and HPV-18 even when using a sensitive pseudovirion-based neutralizing antibody assay. Prospective studies are needed to determine the clinical- and cost-effectiveness of HPV vaccination in HIV-positive MSM aged >26 years.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 12/2013; 64(5):479-487. · 4.65 Impact Factor
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    ABSTRACT: In Canada, hepatitis C virus (HCV) infection results in considerable morbidity, mortality and health-related costs. Within the next three to 10 years, it is expected that tolerable, short-duration (12 to 24 weeks) therapies capable of curing >90% of those who undergo treatment will be approved. Given that most of those already infected are aging and at risk for progressive liver disease, building research-based interdisciplinary prevention, care and treatment capacity is an urgent priority. In an effort to increase the dissemination of knowledge in Canada in this rapidly advancing field, the National CIHR Research Training Program in Hepatitis C (NCRTP-HepC) established an annual interdisciplinary Canadian Symposium on Hepatitis C Virus. The first symposium was held in Montreal, Quebec, in 2012, and the second symposium was held in Victoria, British Columbia, in 2013. The current article presents highlights from the 2013 meeting. It summarizes recent advances in HCV research in Canada and internationally, and presents the consensus of the meeting participants that Canada would benefit from having its own national HCV strategy to identify critical gaps in policies and programs to more effectively address the challenges of expanding HCV screening and treatment.
    Canadian journal of gastroenterology = Journal canadien de gastroenterologie. 11/2013; 27(11):627-32.
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    ABSTRACT: Background & AimsDespite advances in HCV treatment, recent data on treatment uptake is sparse. HCV treatment uptake and associated factors were evaluated in a community-based cohort in Vancouver, Canada. Methods The CHASE study is a cohort of inner city residents recruited from January 2003–June 2004. HCV status and treatment were retrospectively and prospectively determined through data linkages with provincial virology and pharmacy databases. Logistic regression analyses were used to identify factors associated with HCV treatment uptake. ResultsAmong 2913, HCV antibody testing was performed in 2405, 64% were HCV antibody-positive (n = 1533). Individuals with spontaneous clearance (18%, n = 276) were excluded. Among the remaining 1257 HCV antibody-positive participants (mean age 42, 71% male), 29% were Aboriginal. At enrolment, the majority reported recent injecting (60%) and non-injecting drug use (87%). Between January 1998 and March 2010, 6% (77 of 1257) initiated HCV treatment. In adjusted analyses, Aboriginal ethnicity [adjusted odds ratio (AOR) 0.23; 95% CI 0.10, 0.51] and crack cocaine use (AOR 0.61; 95% CI 0.37, 0.99) were associated with a decreased odds of receiving HCV treatment, while methamphetamine injecting (AOR 0.16; 95% CI 0.02, 1.18) trended towards a lower odds of receiving treatment. HCV treatment uptake ranged from 0.2 (95% CI 0.0, 0.7) per 100 person-years (PYs) in 2003 to 1.6 (95% CI 0.9, 2.6) per 100 PYs in 2009. ConclusionHCV treatment uptake remains low in this large community-based cohort of inner city residents with a high HCV prevalence and access to universal healthcare.
    Liver international: official journal of the International Association for the Study of the Liver 11/2013; · 3.87 Impact Factor

Publication Stats

4k Citations
655.61 Total Impact Points

Institutions

  • 2002–2014
    • University of British Columbia - Vancouver
      • • Department of Pathology and Laboratory Medicine
      • • Centre for Disease Control
      • • Department of Anesthesiology, Pharmacology and Therapeutics
      • • Department of Obstetrics and Gynaecology
      Vancouver, British Columbia, Canada
  • 2001–2014
    • BC Centre for Disease Control
      Vancouver, British Columbia, Canada
  • 2012
    • McGill University
      Montréal, Quebec, Canada
  • 2009–2012
    • Provincial Health Services Authority, British Columbia , Canada
      Vancouver, British Columbia, Canada
  • 2010
    • Government of British Columbia, Canada
      Vancouver, British Columbia, Canada
    • BC Cancer Agency
      Vancouver, British Columbia, Canada
  • 2009–2010
    • University of New South Wales
      Kensington, New South Wales, Australia
  • 1998–2009
    • University of Toronto
      • • Institute of Health Policy, Management and Evaluation
      • • Department of Laboratory Medicine and Pathobiology
      Toronto, Ontario, Canada
    • Société canadienne du sang
      Ottawa, Ontario, Canada
  • 2008
    • University of Alberta
      • Department of Medicine
      Edmonton, Alberta, Canada
  • 2005
    • Vancouver General Hospital
      Vancouver, British Columbia, Canada
  • 1999
    • The Princess Margaret Hospital
      Toronto, Ontario, Canada
  • 1993–1999
    • Toronto Western Hospital
      Toronto, Ontario, Canada
  • 1996
    • St. Michael's Hospital
      Toronto, Ontario, Canada