Deadly Public Policy: What the Future Could Hold for the HIV Epidemic among Injection Drug Users in Vancouver

Abstract

The scope and scale of the HIV outbreak that occurred among injection drug users in Vancouver in the late 1990s was unprecedented and resulted in some 2,000 new HIV infections, with incidence rates reaching 18 per 100 person-years. This outbreak, localized mainly in one neighbourhood, cost the Canadian health care system more than 1 billion dollars to diagnose, care and treat. A number of factors combined to stabilize HIV incidence: 1) HIV prevalence became saturated among those at highest risk; 2) several public health policies focused on drug users were implemented, including increased and additional decentralized needle exchange programs, expanded methadone maintenance services, better addiction treatment services, improved housing, and mental health programs; and 3) increased access and expansion of Highly Active Antiretroviral Therapy. To ensure that a similar outbreak never occurs again in Vancouver and other cities, future health policy must consider the political, psychosocial and socioeconomic factors that contributed to this outbreak. These policies must address the unintended adverse consequences of past policies and their repercussions for marginalized individuals living in this community and beyond.

Full text

BEHAVIORAL ASPECTS OF HIV MANAGEMENT (RJ DICLEMENTE AND JL BROWN, SECTION EDITORS)
Deadly Public Policy: What the Future Could Hold
for the HIV Epidemic among Injection Drug
Users in Vancouver
Michael V. O’Shaughnessy &Robert S. Hogg &
Steffanie A. Strathdee &Julio S. G. Montaner
Published online: 8 July 2012
#Springer Science+Business Media, LLC 2012
Abstract The scope and scale of the HIV outbreak that
occurred among injection drug users in Vancouver in the
late 1990s was unprecedented and resulted in some 2,000
new HIV infections, with incidence rates reaching 18 per
100 person-years. This outbreak, localized mainly in one
neighbourhood, cost the Canadian health care system more
than 1 billion dollars to diagnose, care and treat. A number
of factors combined to stabilize HIV incidence: 1) HIV
prevalence became saturated among those at highest risk;
2) several public health policies focused on drug users were
implemented, including increased and additional decentral-
ized needle exchange programs, expanded methadone main-
tenance services, better addiction treatment services,
improved housing, and mental health programs; and 3)
increased access and expansion of Highly Active Antiretro-
viral Therapy. To ensure that a similar outbreak never occurs
again in Vancouver and other cities, future health policy
must consider the political, psychosocial and socioeconomic
factors that contributed to this outbreak. These policies must
address the unintended adverse consequences of past poli-
cies and their repercussions for marginalized individuals
living in this community and beyond.
Keywords Injection drug users .Health policy .HIV
infection .Public policy .Vancouver .Canadian health care
system .Behavioral aspects of HIV management
Introduction
The scope and scale of the HIV outbreak that occurred
among injection drug users (IDUs) in Vancouver between
1996 and 1997 was one of the highest documented in a
high-income country [1–4,5••]. This brief outbreak resulted
in some 2,000 new HIV infections, with incidence rates
reaching 18 per 100 person years [2,5••] and has cost the
Canadian health care system more than 1 billion dollars to
diagnose, care and treat [6]. To place this outbreak in per-
spective, at its peak, HIV incidence among Vancouver’s
IDU population compared to parts of sub-Saharan Africa
on a per-capita basis (http://www.avert.org/aafrica.htm) and
was one of highest ever reported among an IDU population
[7]. Two crucial facts must be considered regarding this
outbreak: first, the HIV outbreak could have been prevented.
Second, scientists, health policy makers and health care
professionals now have the knowledge and tools to prevent
such an outbreak from occurring in the future.
To understand why such an outbreak occurred in this
particular Canadian setting and how to prevent this from
ever taking place again, one first must understand the epi-
demiology of infectious disease and in particular, HIV.
During 1996–1997, some clinics and research studies, such
as the Point Project, and the BC Centre for Disease Control
(http://www.bccdc.org/) began to detect a rise in newly
diagnosed HIV infections among Vancouver’s IDUs [1,
M. V. O’Shaughnessy :R. S. Hogg (*):J. S. G. Montaner
BC Centre for Excellence in HIV/AIDS,
608-1081 Burrard Street,
Vancouver, BC V6Z 1Y6, Canada
e-mail: bobhogg@cfenet.ubc.ca
R. S. Hogg
Faculty of Health Sciences, Simon Fraser University,
Burnaby, BC, Canada
J. S. G. Montaner
Division of AIDS. Department of Medicine Faculty of Medicine,
University of British Columbia,
Vancouver, BC, Canada
S. A. Strathdee
Division of Global Public Health, The Department of Medicine,
The University of California San Diego School of Medicine,
La Jolla, USA
Curr HIV/AIDS Rep (2012) 9:394–400
DOI 10.1007/s11904-012-0130-z

5••]. This was not unusual in comparison to other North
American cities because the efficiency of HIV transmission
through parenteral exposure was well established among
persons sharing contaminated injection equipment and those
exposed to contaminated blood supply during the 1980’s[8,
9]. What differed between Vancouver and other North
American cities was the magnitude of the outbreak that
occurred in a very short period of time. HIV prevalence
among Vancouver’s IDUs rose from 3–4 % to up to 40 %
over several years before becoming stabilized [1,5••,10].
Disproportionate numbers of Aboriginal people, marginal-
ized by poverty, abuse experienced in residential school
systems and cultural dislocation were over-represented
among the city’s IDUs [2,3,5••,11,12].
Why did this happen? The minor rise in HIV prevalence
among the relatively small IDU community in Vancouver
was intensified and propagated by several significant con-
tributing factors. Newly HIV-infected individuals had very
high plasma viral loads, which can heighten the risk of HIV
transmission from a single exposure [10,13–16]. Vancou-
ver’s IDU population was also experiencing a major shift in
drug use patterns from injection of heroin to cocaine, where-
by the frequency of injection rose from 1 to 2 times a day to
up to 40 times per day [2,5••,7,17,18]. The short nature of
the cocaine high [17] is associated with drug binging, in-
creased use of shooting galleries, and trading sex for money
or drugs, all of which can precipitate exposure to HIV.
These events were compounded by an inadequate supply
of sterile needles [17]. Although Vancouver’s needle ex-
change program (NEP) exchanged the highest volume of
syringes in North America at the time of the outbreak (1.5
million per year), it was estimated that as many as 10 million
syringes would have been needed to provide a sterile sy-
ringe for every injection, given the emergence of cocaine
injection [5••]. In fact, at a critical juncture in the city’s HIV
epidemic, funding for Vancouver’s mobile NEP was tempo-
rarily suspended, which further limited sterile syringe access
to the fixed site location in what had become the city’s
epicenter in the Downtown Eastside. A severe shortage of
methadone prescribers also limited drug users’access to this
important medical substitution strategy [5••].
Another important contributor to Vancouver’s HIV out-
break among IDUs was the condensed location of inexpen-
sive, single room occupancy rooms (SROs) in Vancouver’s
poorest neighborhood, the Downtown Eastside [14,15].
Facing a shortage of injection equipment and affordable
shelter, IDUs living in the Downtown Eastside coped by
pooling their money with other IDUs to purchase drugs [14,
15] sharing rooms and needles in SROs that functioned as
de facto shooting galleries. Some hotels with a high density
of SROs were reported to charge re-entry fees to those who
wanted to leave the premises at night, which left many IDUs
unwilling to leave the building to exchange syringes at the
NEP. Once a month, when Vancouver’s welfare checks were
issued on “Welfare Wednesday”, the Downtown Eastside
erupted in chaos, with injection drug use occurring openly
in the streets and alleys. All of these factors converged to
create a perfect storm: the emergence of high-risk IDU net-
works operating in a constricted location, providing a highly
effective route to facilitate HIV transmission.
Current Epidemic in Injection Drug Users
How did the spike in HIV incidence decrease and remain
relatively stable in Vancouver? It was through a combina-
tion of good luck and healthy public policy. Data from a
prospective cohort of IDUs in Vancouver suggest that HIV
prevalence became saturated among those at highest risk.
Those who were most vulnerable due to circumstances such
as injecting multiple times per day, poly-substance use,
engaging in survival sex trade, homelessness, injecting in
shooting galleries, and sharing needles were the first to
become infected during the height of the outbreak [14,15,
17]. In addition, HIV viral loads in the IDU community
decreased over time thereby lowering the risk of HIV trans-
mission [13,19••]. The latter was due to the combined effect
of decreasing individual plasma viral load following sero-
conversion and the introduction of Highly Active Antiretro-
viral Therapy (HAART) [19••].
At the same time, several positive public health policies
were implemented including increased and additional
decentralized NEPs, expanded methadone maintenance
services, access to voluntary HIV counseling and testing,
improved housing, and mental health programs which fo-
cused on the highest risk individuals, increased access to
appropriate HIV and drug treatment services and expansion
of HAART [20].
Insite, the first supervised injection facility in North
America, was established in response to the original HIV
outbreak and the high rate overdose deaths in this popula-
tion that occurred in the mid-1990s [21]. Insite is a low
threshold facility where IDUs can inject illicit drugs under
nurse supervision with provided sterile equipment. While at
Insite, the clients have an opportunity to connect to primary
health care services and drug treatment. Since Insite’s open-
ing in 2003 the site has had more than 1.8 million visits. On
average, nearly 900 visits occur every day, with nearly two-
thirds of these being injection related. In 2010, 221 over-
doses occurred at Insite with no fatalities [22]. Evaluation of
the site has consistently demonstrated its positive impact on
IDUs and the community, including a reduction in injection-
related refuse, improved health status of IDUs, and an
increase in the number of IDUs entering drug treatment
[23–26]. Similarly, the recently concluded medicalized her-
oin trial (NOAMI) [27,28] also implemented in this
Curr HIV/AIDS Rep (2012) 9:394–400 395

neighbourhood at about the same time, has shown better
individual health outcomes associated with the use of med-
icalized heroin as compared to re-initiation of methadone
maintenance therapy, among IDUs who had previously
failed methadone substitution therapy. Of note, unlike Insite,
the future of medicalized heroin in Canada remains in ques-
tion, however, the Federal government may be open to
heroin replacement, like hydromorphone, which is now
being investigated in the DTES [29,30].
However, such progress must not allow complacency, as
there are several factors that make another outbreak highly
plausible. These include the formation of new high-risk
social networks such as street youth injection initiates [31].
New injectors, and long-term injectors, can become vulner-
able as drug use trends change over time and some drugs,
particularly stimulants, such as methamphetamines and co-
caine, are associated with higher injection frequency [17]. In
addition, as Aboriginal populations work to heal residential
school system and cultural dislocation legacies, the demo-
graphic profile of the Aboriginal population (younger, dis-
proportionately IDU and living in poverty in the Downtown
Eastside) requires resources to prevent new HIV outbreaks.
Finally, despite expanded public health programs, the ma-
jority of the city’s IDU population remains concentrated in
the Downtown Eastside. The vulnerability of street youth,
new IDUs and Aboriginal people spending some or all of
their time in this location due to the concentration of neces-
sary resources such as housing, remains high [14].
Another issue of critical importance to preventing future
HIV outbreaks is the large number of HIV-positive individ-
uals. Untreated HIV infection can lead to extremely high
viral loads, and an increased risk of HIV transmission [13,
32]. Work by Wood et al., has shown that the amount of
virus in the community is directly linked to the number of
new infections, as community viral load decreased in the
DTES due to antiretroviral therapy, so do new infections
[19••]. As IDUs are a population of great importance with
respect to antiretroviral therapy due to the difficulty ensur-
ing adherence in active users, and linking them to stable
health care [20,33]. In the late 1990’s, only half of Vancou-
ver’s HIV-positive IDUs who were medically eligible for
antiretroviral therapy were actually receiving it, despite
Canada’s universal health care system [34]. It is therefore
important to expand care, support and services, including
voluntary and supported access to antiretrovirals to this hard
to reach group to keep community viral load and therefore
HIV infectivity as low as possible [35•].
The Future–Preventing New HIV Outbreaks
We are now able to understand how this catastrophic HIV
outbreak occurred in Vancouver and at this point, have the
means to prevent similar HIV outbreaks. Thus, we must use
basic infectious disease epidemiology to implement appro-
priate public policy to better manage HIV by looking at the
agent, host and environment.
Since there is as yet no vaccine to prevent HIV infection,
we are left to manage the virus with available tools and
treatments. The most obvious way to control HIV in this
population is to adopt a combined strategy of targeted pre-
vention among those who are at risk, including education,
harm reduction, addiction and mental health management,
and social support. HIV testing should also be expanded
substantially. A similar approach should also be promoted
among those who are already HIV-infected, as well as
enhancing access to optimized care, support and services,
including voluntary and supported fully free access to anti-
retroviral treatment for all medically eligible individuals.
Policies must reflect the need to expand programs that
enable IDUs to access and adhere to antiretroviral treatment
regimens including peer-based support programs [36] and
medication delivery.
The challenges to primary HIV prevention are vast. There
is no simple solution to reducing the level of drug addiction
and dependence among IDUs. Many IDUs have faced trau-
matizing experiences which have undeniably contributed to
self-destructive behaviors [37], stemming from childhood
sexual and physical abuse and neglect, the multi-
generational effects of the residential school system and
the extreme poverty and marginalization faced by many
IDUs, particularly those of Aboriginal descent [3,14,15].
Therefore, programs that address these socioeconomic, po-
litical and psychosocial issues are critical in the prevention
and treatment of HIV infection. Novel policies must be
implemented which highlight the following objectives: in-
creasing treatment beds especially for youth, women and
Aboriginal people; offering a continuum of addiction treat-
ment that accepts addicts “where they are at”meaning some
may only be ready for prescribed methadone to reduce
rather than abstain from drug use; and expanding IDU
services (i.e., mobile and fixed needle exchange programs,
supervised injection facilities, medicalization of heroin) out-
side of the Downtown Eastside into the surrounding subur-
ban communities [38–41].
How can we prevent a surge of new HIV infections from
happening again in this setting? Most importantly, health
policy makers must be encouraged to create policy and
programs that reflect the future health needs of IDUs and
the environment they live in. For example, the pilot project
“Seek and Treat for Optimal Prevention of HIV/AIDS”
(STOP HIV/AIDS) recently implemented in the DTES and
elsewhere in BC is a new approach to HIV testing and early
detection, to support individuals on treatment by improving
access to HIV/AIDS services, and to ensure a seamless link
between primary and specialist HIV/AIDS services [42].
396 Curr HIV/AIDS Rep (2012) 9:394–400

STOP HIV/AIDS is fundamentally based on the recognition
that optimal antiretroviral therapy use is a highly effective
means of preventing HIV/AIDS morbidity and mortality, as
well as one of the most effective means of preventing HIV
transmission [37,43,44,45•] In addition to HIV, efforts
must be made to reduce transmission of HCV, which is
highly prevalent among IDUs [46]. Policies must be created
through partnerships with affected communities, groups and
other interested parties. We must discourage situations in
which health policy, prevention and treatment initiatives
support epidemiologic homeostasis, a steady state in which
little action is taken and mistakes of the past are repeated.
These efforts must also be made in conjunction with in-
creased surveillance integrate with HCV treatment program,
much like is done with HIV in BC, to assess the effective-
ness of these novel programs and initiatives or to detect a
new outbreak at an early stage. Furthermore, monitoring
HCV incidence in IDU communities serves as a good warn-
ing system and warning signal that HIV rates are soon to
follow a similar trend. The overall aim would be to reduce
impact of both HIV and HCV and its combined effects on
co-morbidities in this community.
Although it is unlikely that rates of HIV infection in the
Downtown Eastside will significantly escalate to the level
that occurred in the mid-1990s, we must ensure that current
and future health policy and environmental triggers do not
enhance the transmission of HIV in this setting. This can be
accomplished by ensuring that all IDUs have adequate ac-
cess to sterile needles/paraphernalia, condoms, safe places
to inject, substitution therapy, and in some cases medical-
ized heroin. As shown, by Marshall et al. [47] the distribu-
tion of condoms with clean needles at Insite has increased
their use by clients. Since Insite’s opening, condom distri-
bution has increased 30 % among those with regular part-
ners and 13 % among those who were single or casually
dating. Furthermore, increases in condom use were also
noted among clients accessing medical care at Insite or
among HIV-positive clients. NEP sites must continue to be
expanded and decentralized [6,20,37–39] outside of the
core of the epicenter, especially since gentrification is dis-
placing high-risk subgroups to new neighborhoods [48]. In
addition, hours of NEP operation should be expanded to 24/
7. Syringe exchange policies must be consistent in all areas
and health authorities and should not be limited to a one-to-
one exchange [18,38,39]. Supervised Injection Facilities,
particularly those that are peer-run, would also be beneficial
in reducing risk of HIV transmission, based on the effica-
cious results of the Insite program [21]. Expansion of these
facilities would promote contact with external health and
social services in addition to encouraging sterile syringe use
[35•]. Prescribed heroin should be made available to eligible
IDUs as described by a recent modeling exercise based on a
Downtown Eastside population [49]. This exercise has
demonstrated the beneficial outcome of Swiss practices
[50], which could lead to significant savings in health and
policing.
Adequate housing is a critical issue in drug policy reform
and must be increased. Numerous articles have previously
linked poor housing to increased susceptibility to HIV and
HCV [14,15,32]. Once HIV seroconversion has occurred,
unstable housing situations and/or homelessness places
IDUs at increased risk of treatment failure or death [14,
15,32]. Re-entry fees into hotels or single room occupan-
cies (SROs) must be eliminated, as they produce similar
risks of increased HIV and HCV transmission for IDUs
through encouraging the reuse of needles, syringe borrow-
ing and risky drug use behavior in general [14,15,32]. The
current housing policies in the Downtown Eastside and
gentrification of the area do not protect IDUs and those at
risk of injecting, rather they create circumstances where
housing in Vancouver is not an option. Thus, these margin-
alized individuals are forced to be homeless and live on the
street, or to move to areas outside of Vancouver proper for
shelter [14,15,32].
Approximately 1 % of the adult population in Vancouver
is HIV-infected [51], with IDUs representing a substantial
proportion of these men and women. To prevent future
outbreaks of HIV in Vancouver’s Downtown Eastside, IDUs
must have better access to HIV testing and early detection,
primary care services, and treatment services (i.e. for sub-
stance and anti-HIV and HCV treatment). Currently, the
number of treatment beds is inadequate relative to the num-
ber needed for this area and the care offered does not readily
cater either to youth or First Nations people. In addition, the
available literature suggests that the antiretroviral treatment
coverage is inadequate in this population [38–40]. Despite
increased uptake of HAART in recent years, approximately
40 % of IDUs who are medically eligible for this life saving
treatment never initiate therapy [39,40,52]. Increased ac-
cess to care and treatment for clinically eligible men and
women would lead to substantially reduced rates of HIV
transmission, HCV transmission and death [34,53]. As
HCV treatment modalities become more effective and better
tolerated, access to such treatments should also be enhanced
[54]. STOP HIV/AIDS provides a template for future work
in this area.
Future Opportunities
Over the last two and a half decades, we have demonstrated
that a concerted, systematic approach can yield successful
outcomes when dealing with a complex interdisciplinary
challenge. The case in point relates to the HIV crisis that
first appeared in our midst in the early 1980s [44]. At that
time, we were confronted with a tremendous challenge,
Curr HIV/AIDS Rep (2012) 9:394–400 397

which not only represented a medical dilemma, but also a
large number of social and cultural issues. While the earlier
response to this formidable challenge was rather fractured
and disorganized, the province of British Columbia soon
understood that a concerted and systematic effort was war-
ranted. A dedicated unit was therefore established embrac-
ing an interdisciplinary approach guided by fundamental
research methodology. It was clear at the outset that close
comprehensive monitoring of the outbreak and the out-
comes associated with various initiatives would be an es-
sential part of a comprehensive response. This allowed for
multiple possible approaches to be formally tested and
through their objective evaluation, those that were shown
to be futile were discarded and those that showed promise
were embraced and incorporated as part of the next round of
iterative testing. Through this exercise, within a decade, we
were able to transform what was once a rapidly lethal
condition into a chronic manageable condition. Over the
next decade, our management strategy was further refined
so that today HIV is not only treatable but also highly
preventable. In fact, today we are at the verge of possibly
controlling and even potentially eliminating HIV with cur-
rently available tools [34,55]. Our research has contributed
substantially not just to address the emerging medical chal-
lenges but also social, cultural, and economic issues that
surround HIV and AIDS.
Recently, the need for coordination of the efforts current
existing in the Downtown Eastside has become broadly
recognized. While this clearly represents a critical part of
the solution, by itself it is unlikely to provide an effective
way forward. Lessons learned in the fight against HIV/
AIDS over the last two and a half decades suggest that in
order to find the way out of the current crisis, we need to
apply a rigorous prospective methodological evaluation of
any efforts to be deployed. In essence, the proposed Down-
town Eastside czar [56], as proposed by a number of com-
munity partners in the past, would help to coordinate all
services in DTES and need the support of an arms-length
evaluation team that can independently monitor the out-
comes of new interventions as they are being deployed so
that futile interventions can be abandoned in favor of those
proven successful within the shortest possible time. It is
only through this concerted, iterative, inter-professional re-
search and evaluation approach that we will able to ulti-
mately conquer the evolving Downtown Eastside crisis. In
doing so, we will be in a position to inform public policy in
Vancouver and abroad. We must ensure that no matter what
programs are introduced, they do not result in significant
unintended negative consequences.
Acknowledgments We would like to acknowledge and honor the
memory of John Turvey, who helped in establishing the first needle
exchange in Vancouver, and the many women who were murdered in
the Downtown Eastside.
Disclosures M. O’Shaughnessy: consultant to Saint Paul’s Hospital;
R. Hogg: none; S. A. Strathdee: none; J. S. G. Montaner: none.
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