Jean-François Boudreau

HIV risk profile of male street youth involved in survival sex

Objectives: To compare HIV risk factors of male street youth involved in survival sex with those of their never involved peers and to describe the sexual activities of the involved youths. Methods: From 2001 to 2003, street youth aged 14–23 years were recruited from street youth agencies in Montreal, Canada. Information was collected on sociodemographic characteristics, substance use, and sexual behaviours. Involvement in survival sex was defined as having ever exchanged sex for money, gifts, drugs, shelter, or other needs. Logistic regression was used to identify HIV risk factors associated with involvement in survival sex. Results: Among the 542 male participants recruited, 27.7% reported involvement in survival sex. HIV risk factors independently associated with such involvement were injection drug using partners (modulated by length of homelessness), unprotected oral sex with male partners, steroid injection, history of sexual abuse, and drug injection. Among involved youths, 32.0% had only female clients, 41.3% only male clients, and 26.7% had clients of both sexes. Unprotected sexual activities were common with clients. However, even more risks were taken with non-commercial sexual partners. Conclusions: Male street youth involved in survival sex are at higher risk for HIV than their non-involved peers not only because of their unprotected commercial sexual activities. They have multiple other HIV risks related to non-commercial sexual activities, drug injection, and sexual abuse. All these risks need to be addressed when providing sexual health interventions for this population.

High hepatitis C virus prevalence and incidence among Canadian intravenous drug users

We used data and leftover samples collected through the SurvUDI network to describe the epidemiology of hepatitis C virus (HCV) infection among injection drug users (IDUs) in Eastern Central Canada. Among the 1380 selected IDUs, having participated twice or more between 1997 and 2003, the overall HCV prevalence rate was 60.4% (95% confidence interval [CI]: 57.7–63.0%). Among the 543 initially uninfected participants, the HCV incidence rate was 27.1 per 100 person-years (95% CI: 23.4–30.9 per 100 person-years). Independent predictors of seroconversion, identified among 359 participants, were age, injecting for a year or less, injecting with a syringe previously used by someone else, injecting most often cocaine, engaging in prostitution, and being recruited in a major urban centre. The HCV epidemic severely affects IDUs in this area. Actions to prevent HCV transmission, such as distribution of sterile injection equipment, have to be reinforced. Special efforts have to be targeted towards starting IDUs.

Hepatitis C virus incidence among young street-involved IDUs in relation to injection experience

BACKGROUND Young injection drug users (IDUs) are at very high risk of hepatitis C virus (HCV) infection. Using a time scale starting at first injection, we studied the period of HCV susceptibility after initiation into drug injection among street-involved IDUs. METHODS A prospective cohort study was carried out among street youth from 2001 to 2005. Semiannual interviews included completion of an interviewer-administered questionnaire and collection of blood samples for HCV antibody testing. HCV-negative subjects currently injecting drugs (last six months) were included in the analyses. Follow-up started at first questionnaire where current injection was reported and ended at seroconversion or at last questionnaire. Poisson regression was used to assess the predictive power of time elapsed since initiation on incidence rate. Kaplan-Meier technique was used to estimate cumulative infection probabilities. RESULTS Among the 858 cohort participants, 145 were injecting at baseline and 60 were injecting at a subsequent questionnaire (45 youth had started injection and 15 had resumed injection). Mean age was 20 years and 62% were males. In the 395 person-years of follow-up, 61 subjects contracted HCV. The HCV incidence rate increased from 16.1/100 person-years during the first year following first injection to 22.4 in the third year, and then decreased to 7.2 in years 7-13 (p=0.02). Median time to seroconversion after first injection was 3.3 years. CONCLUSION The first years after first injection is the period during which vulnerability to HCV is greatest. Our results show the importance of intervening with new IDUs to optimize the chances to successfully prevent infection.

The Challenge of Understanding Mortality Changes among Street Youth

According to a cohort study conducted in Montréal, Québec from 1995 to 2000, the mortality rate among street youth was 921/100,000 person-years. Several new community initiatives aiming to increase access to housing and to social and health services for the homeless were implemented in the city between 2000 and 2003. This study aims to update the mortality rate estimate for the period 2001–2006 and to examine factors that could explain a difference between rates, if any. A second cohort study was conducted between 2001 and 2006. The Cohort 2 mortality rate was computed and compared with the Cohort 1 rate. Several analyses were then carried out: (1) mortality rates in the general population were compared with street youth rates using standardized mortality ratios (SMR); (2) Cohorts 1 and 2 distributions of risk factors for mortality were examined, and their effects were assessed using multivariate proportional hazards regression analyses carried out on a combined Cohorts 1 and 2 dataset. Mortality rate among street youth decreased by 79% while it declined by only 19% in the general population; the SMR for Cohort 1 was higher than for Cohort 2 (11.6 versus 3.0). Multivariate proportional hazards regression analyses yielded estimates that were close to the models estimates based on Cohort 1 data only, and participation in Cohort 1 was an independent predictor of mortality, with an adjusted hazard ratio of 9.0. The mortality decline cannot be completely explained by a similar decrease among the general population or by a difference in distribution of risk factors for mortality between the two cohorts. Field workers suggested that the decrease in heroin consumption they had observed in the streets might have contributed to the mortality decline. We then performed additional analyses which showed that even though the proportion of street youth currently using heroin decreased significantly between 1995 and 2005, the association between heroin use and mortality was not significant (adjusted hazard ratio of 0.9; 95% CI, 0.4 to 2.3). It seems that various factors could have contributed to the decline in mortality rates among street youth, one plausible factor being the implementation of new services for the homeless. This study underscores the importance of monitoring risky behaviors among vulnerable populations to ensure that morbidity and mortality data among these populations is correctly interpreted. Setting up a system to monitor the drug market could improve the quality of information collected.

Risk factors for initiation into drug injection among adolescent street youth

Young injectors are a group with high-risk behaviours, particularly with respect to HIV infection and hepatitis C. A leading strategy to prevent these infections could be the prevention of injection, especially among the youngest individuals. We report analyses on initiation into drug injection from a prospective cohort study of street youth conducted in Montreal, Canada. Among 118 non-injector participants under 18 years of age followed for an average of 1.31 years, we estimated an incidence rate of injection of 22.7 per 100 person-years. Independent predictors of initiation were: a lifetime history of use of ≥4 types of drugs, recent daily alcohol drinking, a recent episode of homelessness, a lifetime history of rape, and recent involvement in survival sex. The observed high rate of initiation into injection clearly indicates that interventions to prevent injection should target especially adolescent street youth. These interventions should address simultaneously individual and structural factors, such as substance abuse and living conditions.

Evaluation of a media campaign aimed at preventing initiation into drug injection among street youth

Aims: A campaign to prevent initiation into drug injecting among street youth who have never injected drugs (NIDUs) was carried out in Montréal, Canada in 2005. Evaluation objectives were (1) to assess the campaigns ability to reach NIDU street youth and (2) to understand the campaigns effects on this population. Methods: A survey was conducted, as well as semi-structured interviews. Findings: The campaign enjoyed a high degree of visibility. It spoke to young NIDUs, causing them to reflect on both drug injecting and their own non-injection drug use. The campaign had a positive impact in terms of their views on drug injecting. Despite its limited scope, young NIDUs also considered the campaign to be a tool with the potential to contribute to preventing initiation into drug injecting among their peers. Conclusions: Media prevention campaigns are able to reach hidden populations through the use of bold and innovative techniques. Such campaigns can also contribute to influencing the attitudes and perceptions of these populations. However, more comprehensive injection prevention programs need to be established.

Modeling Initiation into Drug Injection among Street Youth

This study aimed at examining the predictors of initiation into drug injection among street youth using social cognitive theory framework. A prospective cohort study based on semi-annual interviews was carried out. Psychosocial determinants referred to avoidance of initiation. Other potential predictors were: sociodemographic characteristics, relationships with injectors, parents substance misuse, drug use patterns, homelessness, survival sex, sexual abuse. Independent predictors were identified using Cox proportional hazards regression models. Among the 352 participants, high control beliefs about avoidance of initiation was protective while younger age, daily alcohol consumption, heroin use, cocaine use, and survival sex all increased risk of initiation. Preventive strategies targeting street youth should both enhance youths control beliefs and actual control over their substance use and improve their life conditions.

Correlates of At-risk Gambling Behaviors of Homeless Youth

Objective: This exploratory study aims to describe the gambling behaviors of 419 homeless youth. Methods: Participants were divided into two groups: 1) those whose gambling behaviors did not present a risk (n=366); and 2) those whose gambling behaviors presented a risk (n=53). Results: In this homeless youth cohort, 12.6% exhibited gambling behaviors that could be considered at-risk. Compared to youth not having at-risk gambling behavior, youth with at-risk gambling behaviors were more likely to be male and be born outside of Canada. The at-risk participants were three times more likely to have a diagnosis of mental health disorder and two times more likely to report criminal activities as their main source of income. Conclusions: These findings underline the importance of addressing all at-risk behaviors engaged in by homeless youth.