Contents lists available at ScienceDirect Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep Full length article Substance use patterns among women living with HIV compared with the general female population of Canada ⁎ Mostafa Shokoohia, , Greta R. Bauera, Angela Kaidab, Ashley Lacombe-Duncanc, Mina Kazemid, Brenda Gagnierd, Alexandra de Pokomandye,f, Mona Loutfyd,g,h, On Behalf of the CHIWOS Research Team1 a Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada c Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada d Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada e Department of Family Medicine, McGill University, Montreal, Quebec, Canada f McGill University Health Centre, Montreal, Quebec, Canada g Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada h Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada b A R T I C LE I N FO A B S T R A C T Keywords: Women HIV CHIWOS Substance use General population Canada Background: HIV infection and substance use synergistically impact health outcomes of people with HIV. In this study, we assessed the prevalence of substance use among women living with HIV (WLWH) and compared them with expected values from general data. Methods: Cigarette smoking, frequency of alcohol consumption, last-month non-prescribed cannabis use (vs. last-year use), and last 3 months regular (≥once/week) and occasional (< once/week) use of crack/cocaine, Health & Medical Question Paper

speed (amphetamine), and heroin (vs. last-year use) were examined in WLWH from the 2013–2015 Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS; N = 1422) and compared with general population women from the 2013–2014 Canadian Community Health Survey (CCHS; N = 46,831). Age/ethnoracial-standardized prevalence differences (SPD) and 95% confidence intervals (CI) were reported. Results: Compared to expected estimates from general population women, a higher proportion of WLWH reported daily cigarette smoking (SPD: 26.8% [95% CI: 23.9, 29.7]), smoking ≥20 cigarettes/day (SPD: 11.6% [9.8, 13.6]), regular non-prescribed cannabis use (SPD: 8.0% [4.1, 8.6]), regular crack/cocaine use (SPD: 16.7% [13.1, 20.9]), regular/occasional speed use (SPD: 2.4% [1.2, 4.7]), and heroin use (SPD: 11.2% [8.3, 15.0]). However, WLWH reported lower frequencies of alcohol consumption and binge drinking than their counterparts in the general population. Conclusions: Cigarette smoking and illicit drug use, but not alcohol use or binge drinking, were more prevalent in WLWH than would be expected for Canadian women with a similar age and ethnoracial group profile. These findings may indicate the need for women-centered harm reduction programs to improve health outcomes of WLWH in Canada. 1. Introduction Substance use is a common health risk behavior among people living with HIV (PLWH), who have a demonstrated greater prevalence than their general population counterparts (Ikeda et al., 2016; Mdodo et al., 2015; Tron et al., 2014). Substance use is considered a major barrier to successful HIV care and treatment (Cofrancesco et al., 2008; Cook et al., 2009; Durvasula and Miller, 2014; Gonzalez et al., 2011; Hicks et al., 2007; Malta et al., 2008) despite the substantial advances obtained from combination antiretroviral therapy (cART), e.g., improved life expectancy in PLWH (Antiretroviral Therapy Cohort Collaboration, 2008). Substance use independently or by interaction ⁎ Corresponding author at: Department of Epidemiology and Biostatistics, Health & Medical Question Paper

The University of Western Ontario, K201 Kresge Bldg., London, Ontario, N6A 5C1, Canada. E-mail address: mshokooh@uwo.ca (M. Shokoohi). 1 Please see the list of the names of survey research team in Appendix A. https://doi.org/10.1016/j.drugalcdep.2018.06.026 Received 21 February 2018; Received in revised form 14 June 2018; Accepted 17 June 2018 M. Shokoohi et al. with other factors such as psychiatric disorders and socioeconomic marginalization has the potential to limit the remarkable benefits of cART and pose additional barriers to HIV prevention efforts and medical care (Durvasula and Miller, 2014; Feldman et al., 2006; GonzalezSerna et al., 2014; Gonzalez et al., 2011; Hicks et al., 2007; Malta et al., 2008; Petoumenos and Law, 2016; Vagenas et al., 2015). Previous studies have reported the negative impacts of tobacco smoking (Feldman et al., 2006), problematic alcohol consumption (Vagenas et al., 2015), and illicit drug use (e.g., heroin) (Cofrancesco et al., 2008; Hicks et al., 2007) on HIV care cascade outcomes such as cART non-adherence. The optimal levels of these outcomes are critical in promoting the health of PLWH and maintaining treatment as prevention (TasP) targets (Cohen et al., 2016). Beyond its interruption of care and treatment, substance use can also interfere with cART metabolism and virological response (Barve et al., 2010; Kumar et al., 2015), and contribute to excess mortality (Feldman et al., 2006; Helleberg et al., 2015). For example, in a study of 17,995 PLWH on treatment, smoking increased the rate of death by 1.94 times, with 1.84 and 2.41 times in men and women with HIV, respectively (Helleberg et al., 2015). Substance use vulnerability appears to have greater impacts on HIV and clinical outcomes among women than men with HIV. For example, women with injection drug use (IDU) history and Indigenous ancestry had lower optimal adherence to treatment (47.8%) relative to their male HIV-positive counterparts with (57.7%) and without (83.8%) such vulnerabilities (Puskas et al., 2017). Women with IDU history were also found to be 18% less likely to achieve HIV RNA viral suppression than their male counterparts (Cescon et al., 2013). Other than the unique experiences of HIV infection among women (e.g., pregnancy), drug use along with greater experiences of other psychosocial, economic and structural challenges may account for gender-related differences in HIV outcomes (Cescon et al., 2013; Kuyper et al., 2004; Wood et al., 2008). However, substance use prevalence among women living with HIV (WLWH) has not been well-characterized, particularly in Canada. Population-based research has either overlooked collecting data on WLWH or has not had the adequate sample size to provide estimates for WLWH and comparisons to the broader population (Loutfy et al., 2013; Webster et al., 2018). Women now constitute more than half of all individuals living with HIV worldwide (UNAIDS, 2014) and represent nearly one-fourth of the estimated 75,500 PLWH in Canada; almost doubled from the 1990s (Public Health Agency of Canada, 2015). Understanding the prevalence of substance use in a geographically diverse sample of WLWH relative to general population women is important because of the profound implications for HIV management and to assess the need for harm reduction and socio-structural supports for women who use substances. Therefore, the objective of this research was to characterize the prevalence of cigarette smoking, alcohol consumption, non-prescribed cannabis use, and illicit drug use from the Canadian HIV Women’s Sexual and Reproductive Cohort Study (CHIWOS), a large communitybased research of WLWH in Canada. We estimated the prevalence for substance use in CHIWOS and compared them with data from HIVnegative women of the general population, standardized to the age/ ethnoracial distribution of WLWH. Our aim was to document substance use disparities between WLWH, to explore differences based on HIV status and to identify needs with regard to resource allocation, Health & Medical Question Paper

particularly given the implications of substance use in the context of HIVrelated medical care. 2. Methods 2.1. Participants 2.1.1. CHIWOS sample We used data from the baseline survey of the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS) conducted between 2013 and 2015. CHIWOS is a large communitybased research of WLWH (≥16 years; trans-inclusive: 3.8%), residing in British Columbia (BC), Ontario, and Quebec. Study design and sampling procedure were published elsewhere (Loutfy et al., 2017). Briefly, applying the Meaningful Involvement of Women Living with HIV/AIDS (MIWA) principle, reflecting the recognition of the rights and responsibilities of individuals living with HIV as equal partners to actively engage throughout the design and delivery of HIV/AIDS services to strengthen the responses to HIV/AIDS epidemics (UNAIDS, 2007). A sample of 1422 WLWH was recruited from HIV clinics, AIDS Service Organizations, peers, and online networks (Webster et al., 2018). The survey was administered by Peer Research Associates (PRAs), many of whom also shared the experience of living with HIV were hired and trained in community-based research conduction (Loutfy et al., 2017). The averaged 120-minute-long surveys were administered either through in-person interviews at the clinic, community sites, at the participants’ homes or via phone/Skype. CHIWOS was approved by the Research Ethics Boards of Simon Fraser University, University of British Columbia/Providence Health, Women’s College Hospital and McGill University Health Centre. 2.1.2. CCHS sample We used data from the 2013–2014 cycle of the Canadian Community Health Survey (CCHS), a nation-wide cross-sectional survey administered by Statistics Canada. Detailed documentation is available elsewhere (Canadian Community Health Survey, 2013). Briefly, CCHS is designed to provide nationally representative estimates on health status, health care utilization, and health determinants of Canadians aged 12 years or older residing in private dwellings of all provinces and territories (∼98% coverage), excluding populations living on reserves/ Indigenous settlements, institutions, Canadian Force Bases, and some remote regions. Data are collected using computer-assisted personal and telephone interview software. Consistent with CHIWOS, CCHS analyses were restricted to women aged ≥16 years old, residing in the three provinces (analytic sample = 46,851). Measures of cigarette smoking, alcohol consumption, non-prescribed cannabis use and illicit drug use with similar content and wording were compared between the two surveys. 2.2. Measures Although cigarette smoking and alcohol consumption were collected from all CCHS respondents, measures of drug use were not collected in Ontario and Quebec; for comparability, we provided estimates of drug use for only BC in CHIWOS. 2.2.1. Cigarette smoking In CHIWOS, cigarette smoking history was measured as, “What is your cigarette (tobacco) smoking history?” with four response options (regular, occasional, former, and never). In CCHS, the same question was asked with three response options (daily, occasionally, not at all). To be consistent with the CCHS definition, we categorized WLWH who reported at least one cigarette/day (equivalently, at least 30 cigarettes/ month) as “daily” smokers irrespective of how they were self-identified. As such, 67 self-identified occasional smokers were re-coded as daily smokers, and two cases who reported cigarette smoking regularly were re-coded as occasional smokers. Two measures were created to compare the two surveys: a) nonsmokers at the time of interview (i.e., former or none) versus current smokers (i.e., daily or occasional), and b) a threecategory measure: nonsmokers, Health & Medical Question Paper

occasional smokers, and daily smokers. We also reported cigarette smoking intensity/quantity among current smokers. A five-category measure was created to compare the two surveys: nonsmokers (former or never), < 1 cigarette/day or < 30 cigarettes/month, 1–10 cigarettes/day, 11–19 cigarettes/day, and ≥20 cigarettes/day. M. Shokoohi et al. 2.2.2. Alcohol consumption Last-year alcohol consumption pattern was examined in both CHIWOS and CCHS. A four-category comparable measure was created in each survey: none (did not drink in the past 12 months), ≤1 time/ week, 2–3 times/week, and ≥4 times/week. CCHS measured the monthly pattern of binge drinking as, “How often in the past 12 months have you had 4 or more drinks on one occasion?” with six response categories: never, less than once a month, once a month, 2–3 times a month, once a week, and more than once a week. The same question but in the last month was measured in CHIWOS, with an open-ended response option indicating the number of times. Binge drinking was compared between the two surveys under the assumption that past-year binge drinking patterns were consistent with past month. We created a measure with similar response categories: no alcohol consumed, alcohol consumed but no binge drinking, binge drinking less than once a week (i.e., equivalently, less than 3 times a month), and binge drinking at least once a week (i.e., equivalently, four times or more a month). In CHIWOS, 33 women reported last-month binge drinking without specifying the number of times over the last month; therefore, instead of treating them as missing values, we categorized them into “less than once a week.” 2.2.3. Drug use We compared the use of the following drugs available in the two surveys in BC: cannabis, cocaine or crack, speed (amphetamine), and heroin. CCHS asked respondents, “Have you used [any of these drugs] in the past 12 months?”, affirmative responses were further followed, “How often [did you use any of these drugs in the past 12 months]?” with the following response options: less than once/ month, 1–3 times/ month, once/week, more than once/week, and every day. CHIWOS measured cannabis use as, “What is your cannabis use history?” with the following response categories: a) regularly in the last 30 days, b) occasionally in the last 30 days, c) used in the past year but not in the past 30 days, d) used in the past but not in the past year, e) never used or only ever used it once or twice. To be consistent with CCHS, CHIWOS’s response options ‘b’ and ‘c’ were considered as occasional cannabis use. CHIWOS participants with a positive history of cannabis use were also followed, “Have you used cannabis mainly for medicinal reasons or recreational reasons, or both?” We re-coded medicinal (prescribed) use of cannabis use as non-recreational use, while any other recreational reasons (alone or in combination with medicinal use) were considered as non-prescribed cannabis use. This distinction was made as CCHS aimed to measure the use of illicit drugs, but not prescription drugs. CHIWOS assessed the use of crack or cocaine, speed, and heroin over the last 3 months. Positive responses were additionally followed to measure the frequency of use as, daily, at least once/week, and less than once/week. The same information was assessed in CCHS, but over the past year. Crack and cocaine use were measured in one single question in CCHS, while CHIWOS measured them separately. Therefore, daily use of any of these two drugs was considered as daily crack or cocaine use. For comparison, we created a three-category measure for cannabis use and crack or cocaine use as: none (i.e., former or never), occasional (< once/week), and regular use (≥once/week). As the absolute “n” for speed (amphetamine) and heroin use did not meet the minimum CCHS vetting guideline, we combined regular and occasional use and then created a binary variable for each of these two drugs: none vs. occasional/regular use. 2.3. Data analysis We reported the prevalence and the 95% confidence intervals (CI) of each substance from the CHIWOS sample. We then obtained the prevalence of the same substances from the CCHS sample, using sampling weights that Statistics Health & Medical Question Paper

Canada assigned each respondent to correspond to the number of Canadian residents they represent. The bootstrap variance estimation technique using a set of 500 replicates was used to obtain the 95% CI of the CCHS estimates (Rust and Rao, 1996). To address the imbalanced distribution of age and ethnoracial groups, we used a standardization method which combines stratum-specific prevalence into a single summary estimate through taking a weighted average (Rothman et al., 2008). Standardization obtains these weights in averaging from a standard population. In the present study, these weights were obtained from the CHIWOS dataset and applied to CCHS data. To do this, we created a 16-category variable representing CHIWOS’s age and ethnoracial group distribution (i.e., four age categories: 16–35, 36–45, 46–55, or > 55; four ethnoracial categories: white, African, Caribbean, Black (ACB), Indigenous, or other/multi-ethnicities). We then applied CHIWOS’s age and ethnoracial group distribution to CCHS in order to produce a second set of estimates in which CCHS and CHIWOS samples had a similar distribution with respect to these two variables. The standardized prevalence differences (SPD) were reported to quantify the differences between the two surveys for each substance use. The SPD is a commonly used measure for the purpose of population health assessment and provides information on the public health impact. The SPD was computed by subtracting the CCHS expected estimates standardized to age and ethnoracial groups from the CHIWOS observed estimates; with an SPD greater than zero (i.e., the null) denoting a greater prevalence of the given substance in WLWH. The SPD’s 95% CI was provided using the methods of variance estimates recovery (MOVER) (Zou and Donner, 2008), with 95% CI excluding 0 indicating statistical significance at p < 0.05. The analyses were performed using Stata version 15. 3. Results 3.1. Demographics WLWH differed from the unstandardized general population data by age and ethnoracial groups as well as relationship status, education and yearly personal income levels (Table 1). Greater proportions of women in the unstandardized general population were older and belonged to the white ethnoracial group than WLWH. Other characteristics of these two samples are presented in Table 1, along with the prevalence in the standardized CCHS data. After standardization, the CCHS estimates had identical age and ethnoracial group structure. All subsequent comparisons of substance use were conducted using standardized data. Overall 83% and 87% of WLWH reported taking HIV medication and having a suppressed viral load (i.e., < 50 c/mL), respectively. The median time living with HIV since diagnosis was 11 years (IQR: 7, 17) (data not shown). 3.2. Cigarette smoking (Table 2) A higher prevalence of cigarette smoking frequency and intensity was reported among WLWH compared with estimates expected based on the age-/ethnoracial-standardized women of the general population. Current cigarette smoking (i.e., daily/occasional) was reported by 43.7% of WLWH relative to 17.8% of the expected estimates of general population (SPD 25.9%), indicating that 25.9% (i.e., 259 per 1000) of WLWH reported current cigarette smoking, in excess of what would be expected of Canadian women of similar ages/ethnoracial backgrounds. Daily cigarette smoking was reported by 40.7% of WLWH versus 13.9% of expected estimates from general population women (SPD 26.8%). WLWH tended to smoke a cigarette more intensely than the expected estimates of the general population. 3.3. Alcohol consumption (Table 3) WLWH more frequently reported no alcohol consumption compared M. Shokoohi et al. Table 1 The distribution of age, ethno-racial groups, relationship status, education status, and yearly personal income in the cohort of women with HIV compared with the assumed HIV-negative women of the general population in Canada. CHIWOS estimates (N = 1422) CCHS estimates (N = 46,851)a N % (95% CI) N Unstandardized % (95% CI) Standar …Health & Medical Question Paper