Caitlin Johnston

Sexual violence among a cohort of injection drug users.

The objective of this study was to determine the prevalence of, and factors associated with, sexual violence in childhood, adolescence and adulthood, among injection drug using men and women. The Vancouver Injection Drug User Study is a prospective cohort of injection drug users (IDU) begun in 1996. The analysis included all individuals who completed the baseline questionnaire who responded to a question about sexual assault. Multivariate modeling was used to determine and to what extent a history of sexual violence at different ages is predictive of HIV risk and other health risk behaviors. HIV prevalence was calculated as the total current number of HIV-positive individuals in the cohort. Of the 1437 eligible individuals, 36% reported a lifetime history of sexual violence; 68% of women, and 19% of men (p<0.001). After adjusting for fixed sociodemographics, these individuals were more likely to have ever been in the sex trade, to knowingly share needles/rigs with HIV-positive people, to have attempted suicide, to have ever accidentally overdosed, to binge on alcohol, and to have been diagnosed with a mental disorder/disability. The prevalence of child sexual abuse in this cohort is 21%; 33% for women, and 13% for men. The data show a dose-response relationship between age at first sexual violence and most risk behaviors examined. These relationships are further mediated by gender. The prevalence of HIV among individuals who ever experienced sexual violence was 25%, compared to 19% among those who never experienced sexual violence (p=0.006). Sexual violence, and especially child sexual abuse, is highly prevalent among this cohort, particularly among women. Child sexual abuse has worse consequences for both genders than sexual violence later in life. Nevertheless, women and men are affected differently by sexual violence at different ages, and this has significant implications for health promotion programs, and specifically HIV prevention.

Characteristics of Injection Drug Users Who Participate in Drug Dealing: Implications for Drug Policy

Abstract So-called “balanced” drug policy couples enforcement initiatives targeting drug dealers with health-focused interventions serving addicted individuals. There are few evaluations of this approach, and little is known about how these two populations may overlap. We evaluated factors associated with drug dealing among injection drug users (IDUs) in Vancouver, Canada, and examined self-reported drug-dealing roles and reasons for dealing. Among 412 IDUs seen from March through December 2005, 68 (17%) had dealt drugs during the previous six months. Variables independently associated with drug dealing included: recent incarceration (adjusted odds ratio [AOR] = 2.9; 95%CI: 1.4 – 6.0); frequent heroin injection (AOR = 2.5; 95%CI: 1.4 – 4.6); frequent cocaine injection (AOR = 2.0; 95%CI: 1.1 – 3.8); and recent overdose (AOR = 2.7; 95%CI:1.0 – 7.3). The most common drug-dealing roles were direct selling (82%), middling (35%), and steering (19%), while the most common reasons for dealing included obtaining drugs (49%) and money (36%). Drug dealing among IDUs was predicted by several markers of higher intensity addiction, and drug-dealing IDUs tended to occupy the most dangerous positions in the drug-dealing hierarchy. These findings suggest that elements of “balanced” drug policies may undermine each other and indicate the need for alternative interventions.

Drastic elevations in mortality among female injection drug users in a Canadian setting

Abstract The health and social conditions of women living in Vancouvers Downtown Eastside has recently been the focus of substantial international attention. Since few studies have examined rates and correlates of death among addicted women in Canada, we have characterized patterns of mortality among female injection drug users (IDUs) in Vancouver. The Vancouver Injection Drug Users Study (VIDUS) is a prospective open cohort study of IDUs. The analyses presented here, were restricted to women enrolled between May 1996 and May 2002 and who were aged 14 years or older. We estimated cumulative mortality rates using Kaplan-Meier methods and Cox regression was used to calculate univariate and adjusted relative hazards. Between May 1996 and May 2002, 520 female IDUs have been recruited from the Vancouver area among whom 68 died during the study period. Elevated rates of mortality were observed among those who reported, baseline sex-trade involvement, those with HIV-infection at baseline, and those who lived in unstable housing at baseline (all log-rank: p<0.05). In adjusted analyses, HIV infection (RH = 3.09 [95% CI: 1.86–5.11]; p<0.001), unstable housing (RH = 1.74 [95% CI: 1.10–2.86]; p=0.029) and sex-trade involvement (RH = 1.82 [95% CI: 0.95–3.45]; p=0.071) were associated with the time to death. When the number of observed deaths was compared to the number of expected deaths based on the general female population of British Columbia using indirect standardization, the rate of death among female IDUs was elevated by a factor of 47.3 (95% CI: 36.1–58.5). In Vancouver, female IDUs have rates of mortality almost 50 times that of the provinces female population. Our findings are consistent with a growing number of reports from other settings internationally, and demonstrate the need for an appropriate evidence-based strategy to address the health and social needs of addicted women.

Clients of indoor commercial sex workers : Heterogeneity in patronage patterns and implications for HIV and STI propagation through sexual networks

Objectives: To determine whether “high-risk” clients occupied important sociometric positions in sexual networks of commercial sex workers and to estimate whether they were more likely to be HIV and STI infected. Goal: To determine whether a classification of high-risk clients could be validated by network analysis. Study Design: We used proxy data on clients collected from a cross-sectional survey of 49 indoor female sex workers. Results: Two types of clients were categorized as high risk, including those who created sexual bridges between sex establishments and those who had sex with most or all the FSW at an establishment. High-risk clients were significantly more central and were more likely to be members of cohesive subgroups than were lower-risk clients. The few known HIV and STI infections were in high-risk clients. Conclusions: It is possible to identify theoretically high-risk commercial sex clients from the network perspective using simple data collection and categorization approaches.

How otherwise dedicated AIDS prevention workers come to support state-sponsored shortage of clean syringes in Vancouver, Canada

Abstract Vancouver continues to experience an ongoing HIV outbreak among injection drug users despite the presence of North America’s largest needle exchange programme. The present study utilizes ethnographic interviews and observations conducted with fixed site and mobile van ‘exchange agents’ to examine access to sterile syringes by IDUs in Vancouver between May 2000 and March 2001. Point-for-point exchange continues to be the dominant policy. Ethnographic evidence suggests that there is a large demand for sterile syringes (‘rigs’) when users do not have any to return, indicating policy/practice discrepancies. Despite policy, an intricate rig loaning system has evolved out of agreements made between needle exchange agents and their clients. Restrictive syringe exchange policies lead to considerable unmet needs among injection drug users. Policy makers must change their policies to better address issues of syringe access and in consultation with user groups, develop alternative models of needle distribution and recovery that do not necessarily include exchange.

Violence in the Massage Parlor Industry: Experiences of Canadian-Born and Immigrant Women

We examined and contrasted 129 Canadian-born and immigrant womens experiences of violence and associated structural and interpersonal factors within indoor commercial sex venues. The majority experienced at least one form of structural, interpersonal, or both types of violence, with the attempted removal of a condom during sexual services being cited most frequently. Canadian-born women reported more frequent violent assaults in the survey data. The womens qualitative narratives illustrated that perceptions of violence differed significantly among Canadian versus non-Canadian born women. Findings concerning racialization and gendered relations of power have important implications for prevention and interventions to support victims of abuse.

Community-based HIV and STI prevention in women working in indoor sex markets.

Community research into women’s experiences in the indoor commercial sex industry illustrated an urgent need for sexually transmitted infection (STI) and HIV education, prevention, testing, and treatment and culturally appropriate services to support the sexual and reproductive health of commercial sex workers (CSWs). This work also revealed that a high number of immigrant—primarily Asian—women are involved in the indoor sex industry. In response, the authors developed a community–academic research partnership to design and implement a blended outreach research program to provide STI and HIV prevention interventions for indoor CSWs and their clients. This Community Health Worker Model HIV Prevention and Health Promotion Program incorporated health education, primary care referrals, STI testing using self-swab techniques, and a point-of-care HIV screening test. Here the authors report on program implementation, design, and the experiences of participants and team members and provide research and vaccination recommendations for future work in this area. This work work affirms that community-based service providers can be a key entry point for indoor CSWs to access health care and sexual health promotion and education and may be a solution to missed opportunities to provide culturally and contextually appropriate education and services to this population.

Conducting HIV/AIDS Research With Indoor Commercial Sex Workers: Reaching a Hidden Population

Background: Although comprising up to 80% of the commercial sex industry in Canada, indoor female sex workers (FSW) are generally not represented in research because they are a hidden population and difficult to access. Objectives: This paper describes a community–academic partnership model that was established to gain access to, deliver outreach services to, and conduct community-based research with the indoor commercial sex industry in four cities in British Columbia. Methods: The project employed an ongoing community consultation, peer-delivered approach to reaching this overlooked segment of the commercial sex industry. Peers (former and current FSW) were hired, trained, and supported as outreach workers and participated in the development, implementation, and evaluation of the project. Outreach teams visited sex establishments to deliver harm reduction Observations: During the first 2 years of the project, more than 50 sex establishments were visited by outreach teams and 37 allowed repeat visits. Research interviews have been conducted with 49 FSW in seven establishments from four cities. Conclusions: Although the high cost in terms of time and resources must be recognized, this project represents a successful research and outreach model that permits access to the hidden commercial sex industry.