1. Reaching Those Most at Risk for Drug-Related Harm: Potential Users of a Supervised Injection Service in Ottawa, Canada Ashley Shaw; Lisa Lazarus; Sean LeBlanc ; June Cummings; Dolly Lin; Caleb Chepesiuk; Sheetal Patel; Mark Tyndall, For the PROUD Community Advisory Committee Epidemiology and Public Health May 2, 2014 - 15:00.

2. We have no conflicts of interest to declare. Conflict of Interest Disclosure

3. BACKGROUND: Supervised Injection Services (SIS) A controlled health care setting where PWUID can access clean injection equipment and inject pre-obtained drugs under the supervision of a healthcare professional (Health Canada, 2008) Often includes:  Harm reduction education  Overdose management  Referral to health and social services, including drug and addictions counselling and treatment Currently, there are over 90 SISs in operation around the world, with the majority located in European countries

4. THE EVIDENCE: SISs… Reach the most marginalised PWUID  Who face issues of homelessness, mental health illness, interactions with the law, HIV infection Decrease high-risk injection practices  Sharing injection equipment  Rushed injecting  Injecting in public  Unsafe syringe disposal  No alcohol swabbing of injection sites Reduce harm  Decreased incidence of overdose deaths  Reduced infection rates (Injection-site and blood-borne)  Improved timely access to services (wound care, addictions treatment) No negative impacts on public order and safety

5. THE EVIDENCE FOR SIS Select references from the previous slide… 1. DeBeck, K., Wood, E., Zhang, R., Tyndall, M., Montaner, J., & Kerr, T. (2008). Police and public health partnerships: evidence from the evaluation of Vancouver’s supervised injection facility. Substance Abuse Treatment, Prevention, and Policy, 3, 11. doi:10.1186/1747-597X- 3-11 2. Fairbairn, N., Small, W., Shannon, K., Wood, E., & Kerr, T. (2008). Seeking refuge from violence in street-based drug scenes: women’s experiences in North America’s first supervised injection facility. Social Science & Medicine, 67(5), 817–823. 3. Kerr, T., Small, W., Moore, D., & Wood, E. (2007). A micro-environmental intervention to reduce the harms associated with drug-related overdose: evidence from the evaluation of Vancouver’s safer injection facility. International Journal of Drug Policy, 18(1), 37–45. 4. Kerr, T., Tyndall, M., Li, K., Montaner, J., & Wood, E. (2005). Safer injection facility use and syringe sharing in injection drug users. The Lancet, 366(9482), 316–318. 5. Kimber, J., MacDonald, M., Beek, I. van, Kaldor, J., Weatherburn, D., Lapsley, H., & Mattick, R. P. (2003). The Sydney Medically Supervised Injecting Centre: Client Characteristics and Predictors of Frequent Attendance during the First 12 Months of Operation. Journal of Drug Issues, 33(3), 639–648. doi:10.1177/002204260303300306 6. Marshall, B. D. L., Wood, E., Zhang, R., Tyndall, M. W., Montaner, J. S. G., & Kerr, T. (2009). Condom use among injection drug users accessing a supervised injecting facility. Sexually Transmitted Infections, 85(2), 121–126. 7. Petrar, S., Kerr, T., Tyndall, M. W., Zhang, R., Montaner, J. S. G., & Wood, E. (2007). Injection drug users’ perceptions regarding use of a medically supervised safer injecting facility. Addictive Behaviors, 32(5), 1088–1093. 8. Stoltz, J., Wood, E., Miller, C., Small, W., Li, K., Tyndall, M., … Kerr, T. (2007). Characteristics of young illicit drug injectors who use North America’s first medically supervised safer injecting facility. Addiction Research & Theory, 15(1), 63–69. 9. Stoltz, J., Wood, E., & Small, W. (2006). Changes in injecting practices associated with use of a medically supervised safer injection facility. In 17th International Conference on Reduction of Drug Related Harm. Vacouver. 10. Stoltz, J., Wood, E., Small, W., Li, K., Tyndall, M., Montaner, J., & Kerr, T. (2007). Changes in injecting practices associated with the use of a medically supervised safer injection facility. Journal of Public Health, 29(1), 35–39. 11. Tyndall, M. W., Wood, E., Zhang, R., Lai, C., Montaner, J. S. G., & Kerr, T. (2006). HIV seroprevalence among participants at a Supervised Injection Facility in Vancouver, Canada: implications for prevention, care and treatment. Harm Reduction Journal, 3(1), 36. 12. Vancouver Coastal Health (VCH). (n.d.). Insite - Supervised Injection Site. A health-focused place for people to connect with health care services. Retrieved from http://supervisedinjection.vch.ca/home/ 13. Wood, E., Kerr, T., Stoltz, J., Qui, Z., Zhang, R., Montaner, J. S. G., & Tyndall, M. W. (2005). Prevalence and correlates of hepatitis C infection among users of North America’s first medically supervised safer injection facility. Public Health, 119(12), 1111–1115. 14. Wood, E., Tyndall, M., Stoltz, J., Small, W., Lloyd-Smith, E., Zhang, R., … Kerr, T. (2005). Factors associated with syringe sharing among users of a medically supervised safer injecting facility. American Journal of Infectious Diseases, 1(1), 50–54. 15. Wood, E., Tyndall, M. W., Qui, Z., Zhang, R., Montaner, J. S. G., & Kerr, T. (2006). Service uptake and characteristics of injection drug users utilizing North America’s first medically supervised safer injecting facility. American Journal of Public Health, 96(5), 770. 16. Wood, E., Tyndall, M. W., Stoltz, J. A., Small, W., Zhang, R., O’Connell, J., … Kerr, T. (2005). Safer injecting education for HIV prevention within a medically supervised safer injecting facility. International Journal of Drug Policy, 16(4), 281–284.

6. Potential Users of a Supervised Injection Service in Ottawa  No new sites established in Canada since Insite opened its doors in 2003  TOSCA recommended 2 SIS be opened in Ottawa To determine the potential impact of an SIS in Ottawa, we set out to determine whether the people who face the highest risk of negative health outcomes are likely to use an SIS

7. The Ottawa Context  HCV prevalence is at 60% and HIV is at 11-20% among PWUID in Ottawa  At least 35 people died of overdose in 2011 (Skinner, Regional Supervising Coroner)  2012 TOSCA Study: in the previous 6 months, 20% of PWUID surveyed had experienced non-fatal overdose and 14% had injected with used needles  Limited peer inclusion at all levels PROUD was the community’s response Participatory Research in Ottawa; Understanding Drugs

8. The PROUD Study: GOALS 1.To build community capacity and ownership in all aspects of the PROUD study  Empower the drug using population to develop research that affects their own community 2. To better understand the HIV risk environment among people who use drugs in the Ottawa area 3. To support the development of improved health and harm reduction services  Peer-based HIV testing, supervised injection services

9. The PROUD Study: METHODS Study Design:  Prospective cohort study grounded in a Community-based participatory research (CBPR) framework  Community Advisory Committee Sampling and Recruitment:  From March - December 2013, 862 participants were enrolled into the study using a targeted, street-based recruitment strategy Wave 1: 597 from Ottawa’s downtown core Wave 2: 265 from other areas within Ottawa  Eligibility criteria: Aged 16+ years old; used injection drugs or smoked crack cocaine in the past year; lived in Ottawa for at least three months

10. The PROUD Study: METHODS Data collection:  The PROUD CAC developed a cross-sectional survey covering 8 themes of importance to their community  A trained peer or medical student volunteer administered a one- time iPad-based questionnaire, followed by an HIV POC test (570 HIV tests were administered)  Prospective follow-up will occur through data linkages to health care records available from the Institute for Clinical and Evaluative Sciences (ICES) Statistical analysis:  A descriptive analysis was conducted comparing HIV risk factors among PROUD participants who indicated a willingness to use an SIS and those who did not  Sub-sample analysis of the first 597 participants recruited

11. RESULTS Among the 272 participants who reported injecting drugs in the past 12 months 75.4% reported a willingness to use an SIS in Ottawa Among Potential SIS users:  24.9% had injected with a used needle in the past year  61.3% were unstably housed  74.6% reported a mental health diagnosis  14.2% were HIV positive  18.5% had engaged in sex work in the past year  Among women who reported willingness, 43.1% had engaged in sex work in the past year

12. RESULTS

13. POLICY IMPLICATIONS CURRENT CONTEXT  Providers should be granted an exemption under section 56 of the Controlled Drugs and Substances Act  The Supreme Court of Canada granted a constitutional exemption to Insite in 2011 –> an opportunity for new sites to open  Bill C2 Respect for Communities Act; An Act to amend the Controlled Drugs and Substances Act was reintroduced in October, 2013 FUTURE ACTION  A call for evidence-based policy that facilitates rather than impedes the implementation of proven healthcare services  Support the rights of PWUID to health, safety and access to care

14. CONCLUSIONS AND NEXT STEPS  PWUID continue to face significant drug- related harms and barriers to accessing health and harm reduction services  An SIS in Ottawa would likely reach its target group of high-risk injection drug users  Evidence indicates that an SIS could make a significant contribution toward engaging hard- to-reach populations and reducing harm

15. NEXT STEPS

16. SPECIAL THANKS TO OUR: Community Advisory Committee: Kelly F., Chris D., Dan M., Rick S., Tyler P., Hana D., Alana M., Tarah H., Caleb C., Fred C., Sean L., June C., Christine L., Gilles D., Sharp D Community Partners: Thank you to Ottawa Public Health for their support of the HIV POC testing-component of the project, our medical student volunteers, and our community partners DUAL, OASIS, Ottawa Inner City Health, AIDS Committee of Ottawa, and the Shepherds of Good Hope Funding received from: The Canadian Institutes of Health Research (CIHR), the Ontario HIV Treatment Network (OHTN) and The Ottawa Hospital, Department of Medicine and Division of Infectious Diseases, University of Ottawa

17. For more information: www.supervisedinjectionottawa.com  Supporters Ashley Shaw E-mail: asshaw@toh.on.caasshaw@toh.on.ca Sean LeBlanc E-mail: seanleblanc.dual.ca@gmail.comseanleblanc.dual.ca@gmail.com Mark Tyndall E-mail: mtyndall@toh.on.camtyndall@toh.on.ca Contact Information