Current HIV/AIDS Reports

, Volume 9, Issue 4, pp 394–400

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
Behavioral Aspects of HIV Management (RJ DiClemente and JL Brown, Section Editors)


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.


Injection drug users Health policy HIV infection Public policy Vancouver Canadian health care system Behavioral aspects of HIV management 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Patrick DM, Strathdee SA, Archibald CP, et al. Determinants of HIV seroconversion in injection drug users during a period of rising prevalence in Vancouver. Int J STD AIDS. 1997;8(7):437–45.PubMedCrossRefGoogle Scholar
  2. 2.
    Schechter MT, Strathdee SA, Cornelisse PG, et al. Do needle exchange programmes increase the spread of HIV among injection drug users?: an investigation of the Vancouver outbreak. AIDS. 1999;13(6):F45–51.PubMedCrossRefGoogle Scholar
  3. 3.
    Spittal PM, Craib KJ, Wood E, et al. Risk factors for elevated HIV incidence rates among female injection drug users in Vancouver. CMAJ. 2002;166(7):894–9.PubMedGoogle Scholar
  4. 4.
    Spittal PM, Small W, Wood E, et al. How otherwise dedicated AIDS prevention workers come to support state-sponsored shortage of clean syringes in Vancouver, Canada. Int J Drug Pol. 2003;15:36–45.CrossRefGoogle Scholar
  5. 5.
    •• Strathdee SA, Patrick DM, Currie SL, et al. Needle exchange is not enough: lessons from the Vancouver injecting drug use study. AIDS. 1997;11(8):F59–65. A seminal paper that demonstrated that whereas needle exchange program were crucial for sterile syringe provision, they should be considered one component of a comprehensive programme including counselling, support and education.PubMedCrossRefGoogle Scholar
  6. 6.
    Wood E, Kerr T, Spittal PM, et al. The potential public health and community impacts of safer injecting facilities: evidence from a cohort of injection drug users. J Acquir Immune Defic Syndr. 2003;32(1):2–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Wood E, Kerr T. What to do when you hit rock bottom? responding to drugs in the city of Vancouver. Int J Drug Pol. 2006;17:55–60.CrossRefGoogle Scholar
  8. 8.
    Angelotta C, McKoy JM, Fisher MJ, et al. Legal, financial, and public health consequences of transfusion transmitted hepatitis C virus in persons with haemophilia. Vox Sang. 2007;93(2):159–65.PubMedCrossRefGoogle Scholar
  9. 9.
    Dunn K. HIV and Canada’s hemophiliacs: looking back at a tragedy. CMAJ. 1993;148(4):609–12.PubMedGoogle Scholar
  10. 10.
    Raboud JM, Boily MC, Rajeswaran J, et al. The impact of needle-exchange programs on the spread of HIV among injection drug users: a simulation study. J Urban Health. 2003;80(2):302–20.PubMedCrossRefGoogle Scholar
  11. 11.
    Craib KJ, Spittal PM, Wood E, et al. Risk factors for elevated HIV incidence among Aboriginal injection drug users in Vancouver. CMAJ. 2003;168(1):19–24.PubMedGoogle Scholar
  12. 12.
    Miller CL, Wood E, Spittal PM, et al. The future face of coinfection: prevalence and incidence of HIV and hepatitis C virus coinfection among young injection drug users. J Acquir Immune Defic Syndr. 2004;36(2):743–9.PubMedCrossRefGoogle Scholar
  13. 13.
    West GR, Corneli AL, Best K, et al. Focusing HIV prevention on those most likely to transmit the virus. AIDS Educ Prev. 2007;19(4):275–88.PubMedCrossRefGoogle Scholar
  14. 14.
    Corneil TA, Kuyper LM, Shoveller J, et al. Unstable housing, associated risk behaviour, and increased risk for HIV infection among injection drug users. Health Place. 2006;12(1):79–85.PubMedCrossRefGoogle Scholar
  15. 15.
    Shannon K, Ishida T, Lai C, et al. The impact of unregulated single room occupancy hotels on the health status of illicit drug users in Vancouver. Int J Drug Pol. 2006;17:107–14.CrossRefGoogle Scholar
  16. 16.
    Hermans P. Current review and clinical management of patients with primary HIV-1 infection: limits and perspectives. Biomed Pharmacother. 2001;55(6):301–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Tyndall MW, Currie S, Spittal P, et al. Intensive injection cocaine use as the primary risk factor in the Vancouver HIV-1 epidemic. AIDS. 2003;17(6):887–93.PubMedCrossRefGoogle Scholar
  18. 18.
    Wood E, Lloyd-Smith E, Li K, et al. Frequent needle exchange use and HIV incidence in Vancouver, Canada. Am J Med. 2007;120(2):172–9.PubMedCrossRefGoogle Scholar
  19. 19.
    •• Wood E, Kerr T, Marshall BDL, Li K, Zhang R, Hogg RS, Harrigan PR, Montaner JSG. Longitudinal community plasma HIV-1 RNA levels and HIV-1 incidence among injection drug users. BMJ. 2009;338:b1649. This paper shows that a longitudinal measure of community plasma HIV-1 RNA concentration in Vancouver Downtown Eastside was correlated with the HIV incidence rate and predicted HIV incidence independent of unsafe sexual behaviors and sharing used syringes.PubMedCrossRefGoogle Scholar
  20. 20.
    Vlahov D, Celentano DD. Access to highly active antiretroviral therapy for injection drug users: adherence, resistance, and death. Cad Saude Publica. 2006;22(4):705–18.PubMedCrossRefGoogle Scholar
  21. 21.
    Wood E, Tyndall MW, Qui Z, Zhang R, Montaner JSG, Kerr T. Service uptake and characteristics of injection drug users utilizing North America’s first medically supervised safer injecting facility. Am J Public Health. 2006;96(5):770–3.PubMedCrossRefGoogle Scholar
  22. 22.
    Supervised Injection Site. Research: user statistics. Website: Accessed: April 23, 2012.
  23. 23.
    Wood E, Kerr T, Small W, et al. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. Can Med Assoc J. 2004Google Scholar
  24. 24.
    Stoltz JA, Wood E, Small W, et al. Changes in injecting practices associated with the use of a medically supervised safer injection facility. J Public Health. 2007;29(1):35–9.CrossRefGoogle Scholar
  25. 25.
    Milloy M-J, Kerr T, Tyndall M, et al. Estimated drug overdose deaths averted by North America’s first medically-supervised safer injection facility. PLoS One. 2008;3(10):e3351.PubMedCrossRefGoogle Scholar
  26. 26.
    Wood E, Tyndall MW, Zhang R, et al. Attendance at supervised injecting facilities and use of detoxification services. N Engl J Med. 2006;354(23):2512–4. PubMed171(7): 731–734.PubMedCrossRefGoogle Scholar
  27. 27.
    Oviedo-Joekes E, Nosyk B, Brissette S, et al. The North American Opiate Medication Initiative (NAOMI): profile of participants in North America’s first trial of heroin-assisted treatment. Eur J Epidemiol. 2006;21(7):545–9.CrossRefGoogle Scholar
  28. 28.
    Oviedo-Joekes E, Brissette S, Marsh DC, et al. Diacetylmorphine versus methadone for the treatment of opioid addiction. N Engl J Med. 2009 Aug 20;361(8):777–86Google Scholar
  29. 29.
    Supreme Court of Canada. Canada (Attorney General) v. PHS Community Services Society, 2011 SCC 44, [2011] 3 S.C.R. 134. Docket: 3356, Date: September 30, 2011.Google Scholar
  30. 30.
    Globe and Mail. Harper Tories endorse heroin research project. Published Wednesday, Oct. 12, 2011 9:47PM EDT Website: Accessed: April 23, 2012.
  31. 31.
    Fuller CM, Vlahov D, Arria AM, et al. Factors associated with adolescent initiation of injection drug use. Public Health Rep. 2001;116 Suppl 1:136–45.PubMedCrossRefGoogle Scholar
  32. 32.
    Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med. 2000;342(13):921–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Wood E, Kerr T, Palepu A, et al. Slower uptake of HIV antiretroviral therapy among Aboriginal injection drug users. J Infect. 2006;52(4):233–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Strathdee SA, Palepu A, Cornelisse PG, et al. Barriers to use of free antiretroviral therapy in injection drug users. JAMA. 1998;280(6):547–9.PubMedCrossRefGoogle Scholar
  35. 35.
    • Montaner JS, Hogg R, Wood E, et al. The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic. Lancet. 2006;368:531–6. Commentary showing the role that HAART has in reducing spread of the HIV/AIDS pandemic.PubMedCrossRefGoogle Scholar
  36. 36.
    Kerr T, Oleson M, Tyndall MW, et al. A description of a peer-run supervised injection site for injection drug users. J Urban Health. 2005;82(2):267–75.PubMedCrossRefGoogle Scholar
  37. 37.
    Braitstein P, Li K, Tyndall M, et al. Sexual violence among a cohort of injection drug users. Soc Sci Med. 2003;57(3):561–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Small D, Palepu A, Tyndall MW, et al. The establishment of North America’s first state sanctioned supervised injection facility: a case study in culture change. Int J Drug Pol. 2006;17:73.CrossRefGoogle Scholar
  39. 39.
    Wood E, Tyndall MW, Spittal PM, et al. Unsafe injection practices in a cohort of injection drug users in Vancouver: could safer injecting rooms help? CMAJ. 2001;165(4):405–10.PubMedGoogle Scholar
  40. 40.
    Wood E, Tyndall MW, Spittal PM, et al. Needle exchange and difficulty with needles access during an ongoing HIV epidemic. Int J Drug Pol. 2002;13:95–102.CrossRefGoogle Scholar
  41. 41.
    Wood E, Montaner JS, Tyndall MW, Schechter MT, et al. Prevalence and correlates of untreated human immunodeficiency virus type 1 infection among persons who have died in the era of modern antiretroviral therapy. J Infect Dis. 2003;188(8):1164–70.PubMedCrossRefGoogle Scholar
  42. 42.
    STOP HIV/AIDS. Website; Accessed: April 23, 2012.
  43. 43.
    Montaner JSG, Lima VD, Barrios R, Yip B, Wood E, Kerr T, Shannon K, Harrigan R, Hogg RS, Daly P, Kendall P. Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study The Lancet. Lancet. 2010;376:532–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Montaner JSG. Treatment as prevention—a double hat trick. Lancet. 2011;378:208–9.PubMedCrossRefGoogle Scholar
  45. 45.
    • Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, Hakim JG, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493–505. This clinical trial demonstrates that the early initiation of HAART reduced rates of sexual transmission of HIV and related clinical events, indicating both personal and public health benefits from such therapy.PubMedCrossRefGoogle Scholar
  46. 46.
    McGovern BH. Hepatitis C in the HIV-infected patient. J Acquir Immune Defic Syndr. 2007;45 Suppl 2:S47–56.PubMedGoogle Scholar
  47. 47.
    Marshall BDL, Wood E, Zhang R, et al. Condom use among injection drug users accessing supervised injection facility. Sex Transm Infect. 2008. doi:10.1136/sti.2008.
  48. 48.
    Shannon K, Rusch M, Shoveller J, et al. Mapping violence and policing as an environmental-structural barrier to health service and syringe availability among substance-using women in street-level sex work. Int J Drug Pol. 2008;19(2):140–7.CrossRefGoogle Scholar
  49. 49.
    Miller C, Schechter M, Wood E, et al. The potential health and economic impact of implementing a medically prescribed heroin program among Canadian injection drug users. Int J Drug Pol. 2004;15(4):259–63.CrossRefGoogle Scholar
  50. 50.
    Gerlich M, Gschwend P, Uchtenhagen A, et al. Prevalence of hepatitis and HIV infections and vaccination rates in patients entering the heroin-assisted treatment in Switzerland between 1994 and 2002. Eur J Epidemiol. 2006;21(7):545–9.PubMedCrossRefGoogle Scholar
  51. 51.
    McInnes CW, Druyts E, Harvard SS, et al. HIV/AIDS in Vancouver, British Columbia: a growing epidemic. Harm Reduction J. 2009;6:5.CrossRefGoogle Scholar
  52. 52.
    Wood E, Spittal P, Li K, et al. Inability to access addiction treatment and risk of HIV infection among injection drug users. J Acquir Immune Defic Syndr. 2004;36(2):750–4.PubMedCrossRefGoogle Scholar
  53. 53.
    Willner-Reid J, Belendiuk KA, Epstein DH, et al. Hepatitis C and HIV risk behaviors in polydrug users on methadone maintenance. J Subst Abuse Treat. 2007.Google Scholar
  54. 54.
    Grebely J, Genoway KA, Raffa JD, et al. Barriers associated with the treatment of hepatitis C virus infection among illicit drug users. Drug Alcohol Depend. 2007.Google Scholar
  55. 55.
    Wilson DP, Law MG, Grulich AE, et al. Relation between HIV viral load and infectiousness: a model-based analysis. Lancet. 2008;372(9635):314–20.PubMedCrossRefGoogle Scholar
  56. 56.
    Cheryl Chan, Rich Coleman promises a Downtown Eastside czar. The Province. Friday, February 06, 2009. Accessed April 23, 2012.

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Michael V. O’Shaughnessy
    • 1
  • Robert S. Hogg
    • 1
    • 2
  • Steffanie A. Strathdee
    • 4
  • Julio S. G. Montaner
    • 1
    • 3
  1. 1.BC Centre for Excellence in HIV/AIDSVancouverCanada
  2. 2.Faculty of Health SciencesSimon Fraser UniversityBurnabyCanada
  3. 3.Division of AIDS. Department of Medicine Faculty of MedicineUniversity of British ColumbiaVancouverCanada
  4. 4.Division of Global Public Health, The Department of MedicineThe University of California San Diego School of MedicineLa JollaUSA

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