Cindy Feng

Homelessness Independently Predicts Injection Drug Use Initiation Among Street-Involved Youth in a Canadian Setting

PURPOSE This longitudinal study examines the association between homelessness and injection drug use initiation among a cohort of street-involved youth in a setting of high-prevalence crystal methamphetamine use. METHODS We derived data from the At-Risk Youth Study, a prospective cohort of street-involved youth aged 14-26 years, recruited between September 2005 and November 2011. We used Cox proportional hazards regression to identify factors independently associated with time to injection initiation. RESULTS Among 422 street-youth who had never injected at baseline, we observed 77 injection initiation events during follow-up. Homelessness was independently associated with injection initiation in multivariate Cox regression (relative hazard, 1.80 [95% confidence interval, 1.13-2.87]) after adjusting for crystal methamphetamine use and other potential confounders. CONCLUSIONS These findings highlight that homelessness is a key risk factor for injection initiation among street-involved youth. Supportive housing interventions for street youth may help prevent injection drug use initiation within this high-risk population.

Client demands for unsafe sex: the socio-economic risk environment for HIV among street and off-street sex workers

Objective: Among sex workers (SWs) in Vancouver, Canada, this study identified social, drug use, sex work, environmental-structural, and client-related factors associated with being offered and accepting more money after clients’ demand for sex without a condom. Design: Cross-sectional study using baseline (February 2010 to October 2011) data from a longitudinal cohort of 510 SWs. Methods: A 2-part multivariable regression model was used to identify factors associated with 2 separate outcomes: (1) being offered more money for sex without a condom in the last 6 months; and (2) accepting more money, among those who had been offered more money. Results: The sample included 490 SWs. In multivariable analysis, being offered more money for sex without a condom was more likely for SWs who used speedballs, had higher average numbers of clients per week, had difficulty accessing condoms, and had clients who visited other SWs. Accepting more money for sex without a condom was more likely for SWs self-reporting as a sexual minority and who had experienced client violence and used crystal methamphetamine less than daily (versus none) and less likely for SWs who solicited mainly indoors for clients (versus outdoor/public places). Conclusions: These results highlight the high demand for sex without a condom by clients of SWs. HIV prevention efforts should shift responsibility toward clients to reduce offers of more money for unsafe sex. Programs that mitigate the social and economic risk environments of SWs alongside the removal of criminal sanctions on sex work to enable condom use within safer indoor workspaces are urgently required.

Prescription opioid injection and risk of hepatitis C in relation to traditional drugs of misuse in a prospective cohort of street youth

Objective Despite dramatic increases in the misuse of prescription opioids, the extent to which their intravenous injection places drug users at risk of acquiring hepatitis C virus (HCV) remains unclear. We sought to compare risk of HCV acquisition from injection of prescription opioids to that from other street drugs among high-risk street youth. Design Prospective cohort study. Setting Vancouver, British Columbia, Canada from September 2005 to November 2011. Participants The At-Risk Youth Study (ARYS) is a prospective cohort of drug-using adolescents and young adults aged 14–26 years. Participants were recruited through street-based outreach and snowball sampling. Primary outcome measure HCV antibody seroconversion, measured every 6 months during follow-up. Risk for seroconversion from injection of prescription opioids was compared with injection of other street drugs of misuse, including heroin, cocaine or crystal methamphetamine, using Cox proportional hazards regression controlling for age, gender and syringe sharing. Results Baseline HCV seropositivity was 10.6%. Among 512 HCV-seronegative youth contributing 860.2 person-years of follow-up, 56 (10.9%) seroconverted, resulting in an incidence density of 6.5/100 person-years. In bivariate analyses, prescription opioid injection (HR=3.48; 95% CI 1.57 to 7.70) predicted HCV seroconversion. However, in multivariate modelling, only injection of heroin (adjusted HR=4.56; 95% CI 2.39 to 8.70), cocaine (adjusted HR=1.88; 95% CI 1.00 to 3.54) and crystal methamphetamine (adjusted HR=2.91; 95% CI 1.57 to 5.38) remained independently associated with HCV seroconversion, whereas injection of prescription opioids did not (adjusted HR=0.94; 95% CI 0.40 to 2.21). Conclusions Although misuse of prescription opioids is on the rise, traditional street drugs still posed the greatest threat of HCV transmission in this setting. Nonetheless, the high prevalence and incidence of HCV among Canadian street youth underscore the need for evidence-based drug prevention, treatment and harm reduction interventions targeting this vulnerable population.

Police confrontations among street-involved youth in a Canadian setting

BACKGROUND Street-level policing has been recognized as a driver of health-related harms among people who inject drugs (IDU). However, the extent of interaction between police and street-involved youth has not been well characterized. We examined the incidence and risk factors for police confrontations among street-involved youth in a Canadian setting. METHODS Using data derived from participants enrolled in the At-Risk Youth Study (ARYS) between 2005 and 2011, we assessed factors associated with being stopped, searched, or detained by police without arrest in the previous six months using generalized estimating equations (GEE) with logit link for binary outcomes. RESULTS Among 991 participants followed during the study period, 440 (44.4%) reported being stopped, searched, or detained by police for an incidence density of 49.20 (95% confidence interval [CI]: 36.42-65.01) per 100 person years. In multivariate GEE analyses, factors associated with police confrontations included: male gender (adjusted odds ratio [AOR]=1.35), homelessness (AOR=2.05), recent incarceration (AOR=1.78), daily cannabis use (AOR=1.31), daily heroin injecting (AOR=1.36), crack pipe/syringe sharing (AOR=1.61), injection drug use (AOR=1.37), public drug use (AOR=2.19), sex work involvement (AOR=1.67), and drug dealing (AOR=1.49) (all p<0.05). In total, 19.0% of participants reported that police confiscated their drug paraphernalia without arresting them. Additionally, 16.9% of individuals reported experiencing violence at the hands of police. CONCLUSION We found that various factors, such as homelessness and markers of more severe addiction, increased the likelihood of being confronted by police, and police confrontations were associated with markers of health-related harm among street youth. These findings highlight the need for social and structural interventions that best enable police to fulfil public safety and public order objectives without negatively influencing health behaviours of street youth.

Transitions into and out of homelessness among street-involved youth in a Canadian setting.

The impact of transitions in housing status among street youth have not been well explored. This study uses a generalized linear mixed effects model to identify factors associated with transitions into and out of homelessness among a prospective cohort of 685 drug-using street-involved youth aged 14-26. In multivariate analysis, high intensity substance use, difficulty accessing addiction treatment, incarceration, sex work, and difficulty accessing housing (all p<0.05) either significantly facilitated or hindered housing transitions. Findings highlight the importance of external structural factors in shaping youths housing status and point to opportunities to improve the housing stability of vulnerable youth.

Gender influences on initiation of injecting drug use

Abstract Background and objectives: Gender differences in illicit drug use patterns and related harms (e.g. HIV infection) are becoming increasingly recognized. However, little research has examined gender differences in risk factors for initiation into injecting drug use. We undertook this study to examine the relationship between gender and risk of injection initiation among street-involved youth and to determine whether risk factors for initiation differed between genders. Methods: From September 2005 to November 2011, youth were enrolled into the At-Risk Youth Study, a cohort of street-involved youth aged 14–26 in Vancouver, Canada. Cox regression analyses were used to assess variables associated with injection initiation and stratified analyses considered risk factors for injection initiation among male and female participants separately. Results: Among 422 street-involved youth, 133 (32.5%) were female, and 77 individuals initiated injection over study follow-up. Although rates of injection initiation were similar between male and female youth (p = 0.531), stratified analyses demonstrated that, among male youth, risk factors for injection initiation included sex work (Adjusted Hazard Ratio [AHR] = 4.74, 95% Confidence Intervals [CI]: 1.45–15.5) and residence within the city’s drug use epicenter (AHR = 1.95, 95% CI: 1.12–3.41), whereas among female youth, non-injection crystal methamphetamine use (AHR = 4.63, 95% CI: 1.89–11.35) was positively associated with subsequent injection initiation. Conclusion: Although rates of initiation into injecting drug use were similar for male and female street youth, the risk factors for initiation were distinct. These findings suggest a possible benefit of uniquely tailoring prevention efforts to high-risk males and females.

Successes and gaps in uptake of regular, voluntary HIV testing for hidden street- and off-street sex workers in Vancouver, Canada

Despite evidence globally of the heavy HIV burden among sex workers (SWs) as well as other poor health outcomes, including violence, SWs are often excluded from accessing voluntary, confidential and non-coercive health services, including HIV prevention, treatment, care and support. This study therefore assessed the prevalence and association with regular HIV testing among street- and off-street SWs in Vancouver, Canada. Cross-sectional baseline data were used from a longitudinal cohort known as “An Evaluation of Sex Worker’s Health Access” (AESHA; January 2010–July 2012). This cohort included youth and adult SWs (aged 14+ years). We used multivariable logistic regression to assess the relationship between explanatory variables and having a recent HIV test (in the last year). Of the 435 seronegative SWs included, 67.1% reported having a recent HIV test. In multivariable logistic regression analysis, having a recent HIV test remained significantly independently associated with elevated odds of inconsistent condom use with clients [adjusted (multivariable) odds ratios, AOR: 2.59, 95% confidence intervals [95% CIs]: 1.17–5.78], injecting drugs (AOR: 2.33, 95% CIs: 1.17–4.18) and contact with a mobile HIV prevention programme (AOR: 1.76, 95% CIs: 1.09–2.84) within the last six months. Reduced odds of having a recent HIV test was also significantly associated with being a migrant/new immigrant to Canada (AOR: 0.33, 95% CIs: 0.19–0.56) and having a language barrier to health care access (AOR: 0.26, 95% CIs: 0.09–0.73). Our results highlight successes of reaching SWs at high risk of HIV through drug and sexual pathways. To maximize the effectiveness of including HIV testing as part of comprehensive HIV prevention and care to SWs, increased mobile outreach and safer-environment interventions that facilitate access to voluntary, confidential and non-coercive HIV testing remain a critical priority, in addition to culturally safe services with language support.

Income level and drug related harm among people who use injection drugs in a Canadian setting.

BACKGROUND Higher income is generally associated with better health outcomes; however, among people who inject drugs (IDU) income generation frequently involves activities, such as sex work and drug dealing, which pose significant health risks. Therefore, we sought to examine the relationship between level of income and specific drug use patterns and related health risks. METHODS This study involved IDU participating in a prospective cohort study in Vancouver, Canada. Monthly income was categorized based on non-fixed quartiles at each follow-up with the lowest level serving as the reference category in generalized linear mixed-effects regression. RESULTS Among our sample of 1032 IDU, the median average monthly income over the study follow-up was

Pregnancy intentions among female sex workers: recognising their rights and wants as mothers

1050 [interquartile range=785-2000]. In multivariate analysis, the highest income category was significantly associated with sex work (adjusted odds ratio [AOR]=7.65), drug dealing (AOR=5.06), daily heroin injection (AOR=2.97), daily cocaine injection (AOR=1.65), daily crack smoking (AOR=2.48), binge drug use (AOR=1.57) and unstable housing (AOR=1.67). The high income category was negatively associated with being female (AOR=0.61) and accessing addiction treatment (AOR=0.64), (all p<0.05). In addition, higher income was strongly associated with higher monthly expenditure on drugs (>

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400) (OR=97.8). CONCLUSION Among IDU in Vancouver, average monthly income levels were low and higher total monthly income was linked to high-risk income generation strategies as well as a range of drug use patterns characteristic of higher intensity addiction and HIV risk. These findings underscore the need for interventions that provide economic empowerment and address high intensity addiction, especially for female IDU.